Murray, Buell Form VS.4L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit can be signed only by th• 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— (4..
Village
Dist. No County. .i...t..icl ...i,r.v.4.--- or City
(If city, give street address)
7, 1 -
Name of deceased 11-"." ::V-I diLi. '7. -T (7 4 i Veteran
(If veteran, give name of War)
Single, married, widovied,
Sex I Color or,divorced (write the word) Date of Death a..ot' ..i./ .19`1Z-
Age ti.aYears.
-7 1 Months ..,._...Days-t.- Birthplace /
Cause of D ath
Certificate was signed by c.c
I.&.
M.D.....,
Address %1 (
Place of Burial (or Removal).. .../. ., m--- ' —7'
/
(If body is to be temporarily held,fill ce la
Cemetery..4kN.4-...k.. .4-4,,, it k...4--' Date of Burial I6 L.02 19 C-6
(If body is to be temporarily held,All I space later) "
Thg Certificate of Death containing the abov4 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
Number, __ AM the basistthereof I HEREBY GRANT A PERMIT
(..._ _
to _,
i. ,
a /.L . .,-;,k11..7/ L.. , t
maw the .. .d,,arno
./..
/..,2.4-.4.,-.-r-.4. to hold temporarily and the bar.
(Undertaker or person having chargestfnorpse) (41eas',rr, n
e, °the dispose of[state how])
Dated / ic:' 19 .-I (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (mtbject 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 �..-
(-'°-e)-t
Date oP .7L. " '�`-`" wad, lct /<3 19 L-5-6
(Interment oa-"Gramaiian)1
L-J 1. C• yG ,iC/(,;2-'""d' 27,1 °T2Z..•.0 '
(Name of Cemetery, Crematorium, etcy
•
Section Lot No / -/4'5Grave No:�
(Signed) / l C•414 � sl eer'L 2.C....'
(Person in charge)
Address C<" L. '/ --4 +
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
violati. ' 'he 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.
r'