Williams, Henrietta Form vs.at. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit eau 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__/ 16
Village n -
Dist. No /Couaty........ .. z � or City %z<%;k ,l. t-t=%
��— ' (If city, give street address)
Name of deceased..•... ...• ...G IY..7�i?:C�C . r,. ...../' -%� >l; G2 Veteran
ingle married widowed / ((f veteran, give name of War)
Sex• y'` , Color..�„�...... r divorced (wnte the word)... .zx�t�� Date of D � ?....�l9.. :�
Age /c2 Ye s Months r ,...Days B' pla E �. Za.... ..... .. .
u Ca se of Death.... . .y..�,ys/ .... ��;�:�4��•C�-2�r
Certificate was signed by.. M.D.
Address - c, r * `y . j„
Place of Burial (olRemoval) v- r
(If body is to be temlfo ily held, ll In spar late )
Cemetery ,:(.4:3,l. '=-r""�L:' t Date of Burial // 19 �S
(If body is to be temporarily held,all in space later)
T,hq 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num 14,
, and on the basis t reof I HEREBY GRANT A PERMIT —
to .ri.c. •:y .Gr��..• .., �. 'ress) .: '-
(Add
the i .... .•. .. to hold temporarily and .44,4,i" the body
-
(Underta or person haying charge of corpse) (In r,remoy or oth se dispose of (state bow))
Dated a./ 19 s._:; (Signed) .a. R i
Local Registrar
This Permit is su cient for the Removal (and Interment or Cremation) of a body to any part of the State (subject 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
PBEIJISFS ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date t?/I/.it�. , —was -.._ 4. ( 19 (. S
(Interment of )
2
7/ CL-7----"`----tr.' '
(Name of Cemetery, Cremator i.m, etc.)
Section 2 Lot No. Grave No. Z
(Signed) �a- . --�en
(Person in charge)
n
�� �( j 1
Address(J(J � - ,
Person in charge must 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.