Hopkins, Ella Form o&IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be 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 CERTIFICAT OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK- Town Registered No.__.. .2..Y
Village
Dist. No....3. .94..County........QNE,,TDA or City MARCY
(If city, give street address)
Name of deceased . 1'e31 Veteran
// Single, married, widowed, (If^veteran, give name of w.x)
Sex ' Colonmtl.t.I or divorced (wnte the word) Date of Death /tav, G.t 19 55
Age S 7 Years ? Months.... . „ ..Days Birthplace....,....
Cause of Death.... eLet.RIC.t.4..S.. :4�l..SI4R.�A�e!W....�F�.��.�...... . . .sitirzi�. .� •��iP.lel.e��'�'4GR,9RJ0
Certificate was signed by ... . M.D.
�n ,
Address `.!!►'.{r ......S.�'. .. . .. . . � .....��Y�.si3itnP.�4�.,e� ,
Place of Burial (or emova v
(If body is to b posy_i id,fll spa lat / •
Cemetery.... J..Oi $.�L4I+ A.. ..�..w Date of Burial / .. ... Jt,� 19
(If body i to be temporarily held,8ll in space late
The Certificate of Death containingthe above stated particulars, having been presented to ml, after careful exami-
nation, the same appearing to be OMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hav accepted the a for registration, have recorded it in my Local Record with the above stated Registered
N m , on asis thereof I H BY �G NT A PERMIT,
to... �cc..4 n.e.1 ..,. t.M?J1d.gli.c ... ... . 1.1. +. i~11 . . i�� . 71 ,
1 ' �np (Name) (Address) , .
the C,l114.1ili .ti. AM to hold temporarily a d ei the body.
(Under ker or rsolpaving charge of corpse) (Inter,r ov ,or o ervri dime of[state Low))
Dated......./..J. ...(p 6..16 19 (Signed)
Deputy Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod to any part of the State (enbject to local
cemetery or other regulations),unless removal is by common carrier, in wl ich case a Transit Permit (VS No. 62) is required.
C�"-yie- zT ,
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date %i u� '.rz..- _ �an �2�_ 7 19
(Interment or-CrPewaikon)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. 2 Grave No. l
(Signed) .,%�Cl�r-.4 mot - '—'7.Z-(i j'
y�/i
(Person in charge) �-
, - / . ,
,-
..,,7
Addresue'G-'r//-G-? „.> '�-k-- sC. 0-tom/.. /� L 4j/
f.
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.