Marshall, Ruth Form vs.EL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr 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 INKt#
Town egiatered No._..,��
/,� Village
Dist. Ne--�/ Courlty..._i d .L•..s�..., or City
(If city, give street address)
Name of deceased.... e. Veteran
Single, married, widowed, ( veteran. al a name of wax)
SA lor. . j r divorced (wntg the word}.... . Date of 1Z
Age Years /....Q Months .......Days Birthplace
Cause of Death
Certificate was signed by M.D.
Address dr .. .g... .. . _
Place of Bur. .. V,.emov 1 ..... ... . . ... .. . ... /�
(If body Is to .-` ra ly held, 1 I nee ate
Cemetery. •0 • . . Date of Burial 17 19c.S6
(If body Is to . emporarily held,fill In space later)
The 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 ;f cepted the same for registration, have r orded it in my Local •ecord with the above stated Registered
Nuy and / •e basis th •f I H • .•BY 'kill'. NT A PERMIT , �i
...
(A••.Fees)
the .O. . .ApdP' ,„'40:1 .. . 0 ... - 1..•ddir 44.0 . . 7°7
to hold temporarily and a... the body.
( dertaker or rson }}suing charge rpse) (Inter, remove .r#:‹Zise di �r.//[state how])
Dated. /A. 19.4 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (mu•tect 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 f// z 7 19 '
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section , - Lot No. - 3 Grave No. 47
� F
(Signed) r L� n,, -C-, Ce )
A.
(Person in charge)
Address ..(/"J J .
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. - P'f 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.