Jones, Mary Forza Ys.QIL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL �(OR REMOVAL) PERMIT
its Thin Pormit can be ,*nod cdy by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village. or City) in which tho death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.. Town Registered No.__.._.............._
� i"Il lage e
Dist. No../ -
County,J\,c C'..•&,..:;c.'( .tA er£its L:I ' t .,.r'kl—CL LC, I( ' tl
` (If city, give street addreee) �/
Name of deceased �?`,. %..s Veteran YY9
tf Sin I . marrie !widowed, (l�rele�nn, give name of War)
Sex:.7:74 .t;.Color 1 4.�",...or di reed (write the word).ti.�.t\. .L'....Date o Deat . :.. r(i-0,-{,,
/ ... .1..0
Age to. /.....,Ye rs.... Months.. . .,. ,,.. ay. ' irthplace.. �..r.. � R 79. RCause o£ Death 4a. ..w. Lt. .` ,, ..N tt r.. -.i,,,i't-
t�
Certificate was signed by :1:. +�,, � ...r M.D.
Address . \4
Place of Burial (or Removal) Aps.,c,2441,4.4...j,--ids..n,-;,1 . V1�.( . .
(if body Is to be temporarily held 11 to space 1 ter) ++ a r
Cemetery �1.!„l�,f, ,4`�' I Date of Bukll t2 ' ' ? 19.3..E
(If body t to be temporarily held, till in space later)
Eh4 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 aline for registration, have recorded.it in my Local Record with the above stated Registered
Number, apj on the basis ,hereof I lidEREBY GRANT A PERMIT
(Name) -r- (Address)
he i..&Lti.(.1:1:r:., to hold temporarily and „k,; th( body.
( der er or perron, aving ebergu aF corpee) (,titer, removeslor otberir ,dls f(state how )
Dated I 19..5. ,. (Signed) I .QL.i..N..� ',4.- .' C:.., �� ?>-11,4 f
' Local Registrar
This Pewit is ouffcion'Z for the Removal (and Interment or Cremation) of a body to any part of the State (sash ct to local
:emetery or other regulations), unless removal in by common carrier, in which cane a Transit Permit (VS No. 62) is required.
ENDORSTAIENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CRNMATIONS
ARE MADE �i C
_c
Date of /G1i+�.z, / was // 19 U
^� (Interment. or "on
(Name of Cemetery, Crematorium, 'etc.)
Section Lot No.3 / ' Grave No.
/7/
(Signed) 7711�� L t_.C f
(Person, in char
�xn /fir
Address
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 pf 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.