Valentine, Louise Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH 1' ' ''
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dr 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 County or City
_ (If city, give street address)
Name of deceased . Veteran
(If veteran. Give name of Wer)
Single, married, widowed, J/
Sex Color or divorced (write the word) if 'u1.4)7' Date of Death 19.:.
Age Years Months..., Days Birthplace
74/
Cause of Death t--(t- a.1 r,
f
Certificate was signed by .:., ; :�:..r . (-- M.D.
.. .
Address - .,.i � ..
Place of Burial (or Removal) " ' l- . .(If body la to be temporarily held,ell is space later)
Cemetery ..ri!�G.1....... Date of Burial / f 19
(If body is to be temporarily held,all 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT )
to
(Name) t (Address)
the ;r to hold temporarily and. _., the body.
(Undertaker or person having charge of corpse) red or th dimose o state how])
Dated ✓....... r " 19 (Signed) r
al
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (wbjeet to local
cerro;.ery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. (62) is required.
r
4777
ENDORSRENT OF SEXTON OR PERSON IN CHARGE OF
PRE Mf I SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
�` =�
d.
Date o / wa�9 �' 19°
(Interment or Crjt�ion)
''''_ 7s
/".e. .."7/‘ -of.-2,.......---i---1--s.s_r
(Name 3 Cer metery, Crematorium, etc.)
Section 5 7 Lot Nol Y' /?O L Grave No. �'
/ t �
(Signed) 1/7 4
(Person in charge)
Addre SS rzy,,", ,A, x(6Agg
Person in charge mist 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 wards
"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.