Tucker, Baby Girl Form V&u. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er This Permit can ha signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No_J./..,s..
‘ % Village
Dist. No 5- 67/County -/-; -
l kem-a-:-. 7-3.-r or City ,V ,Liet .. 1(
(If city,give street address)
Name of deceased 44- 5j ""&:,---t-41 .4-V.4.rirr....16:7-'-' Veteran i-r_e---
(If ve)57. give name of War)
i„. „....C8 ,--
Sex:jj ingle, married, widowed,
4w4C.L.Color. /fe1/414..or divorced (write the word) -t....f.,-$7)-4....., Date of Dea Cc , 3 0 19 ,-)--.0
Age - Year ,--) — ...Months - Daysie 4-:. Birthplace -"7‘-ee ..........r N.
Cause of Death
Certificate was signed by M D
Address 3./-r4, 7.- . ' ... 41.71/7 , •
Place of Burial (or Removal) r,.../....a.. . rite...- erf:.<,64 &',I,
(If body is to be /7 tesgo_rarily held, fill in space la,W1 -, --
Cemetery ..441.--,-7: .--V. - Iv. "--Y`6-Cc- Ce-soi Date of Burial (...i./..i..., .1/ 19.>.S.f.S
(If body is to be temporarily held,fill in space later)
Thn Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on the basis tltiof I HEREBY GRANT A PERMIT
to 7 .4'..a.-4./-- )7
il_,,,c,., V:... ._0..,1612316 (Address)
the to hold temporarily and the body.
Made r or person having charge of corpse) ,tierrt,.eziov lm otherwi diose of Wats bow])
Dated si./ 1925.7'..S.- (Signed) eç
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (lubject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was 19 p 's'
Lgisdigsjimk..(Interment
or Cremation)
9/71,4W ALuz-4a1P/1-
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) Li,,-?. /vl "1f�.i0`�J
(Person in charge) //
�
y/L ? v
Address
Person in charge mist return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.