Booth, Julie Form vs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town._., Registered No._ _-........
•: Village-
Dist. No C' County.. or City t' _ -•
4 f eit3I ive s a t s)
iiib
Name of decease . ..r5.. — let r• ' o o
�, Single, married, widowed, (If veteran, s,ve�name•of war
Sex 1...,%)
'2 Color... ' ' or divorced (wnte the word)-LA.A " a of Death Lk — 19`•.'....
Age esk \. ars Months a,.,.Z2.:... -a Birth `10,0
1.
Cause of Deatla.en- tu,. 1.1'N
Certificate was • .........., ... M.D.
M.D.
Adsir .. :....'. .....
Place 4 B ria (or Remova))
(If bod*tato he �porarlly beItl 11111•In space later) a
Cemetety V �..R �52.3,...r —�7
.14., Date of B i~ .. t T�
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presen d 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
and on the .asis thereof, HEREBY GRANT A PERMIT
to L - ��c7 T) r1
� ,-••�� � `•��) �TV1.�:.... +,--�R.JI lean
Via, ►'•+ ���••• r • ... •hold temppcarly and.... the body.
r or person ha g barge of corpse) ' (Inter,remove,or e of Is WI)
Dated.e..a `. . .. .. ..9. .19. (Signed) ..:, '
r '514Local egfstrar
This 'Permit ' ufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other lations), 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
Y n
Date of was(4L1_../ 1/196
(Interment or Cremation)
(Name of Cemetery, Creme rim', etc.)
deer .4.353°
Section ? Lot Not/ . Grave No.//
(Signed) e/t'Cx ,,,,,
(Person in charge)
// g7r.
Address Ce)1 l/l — 0`��� � s4, .Jo,
Person in charge Deist 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.