Thomson, Eliza v`j--7/ , f.� --
Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to Thu Permit can be signed only by tie 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._ v
Village G.,
Dist. No S� J County... :.a.-1.2 :. or City .,j,,,,: ,.:4,f - --
c J ` (If city, give street address)
Name of deceased / �� '? Veteran
Single, mar '`d, widowed, - �: (l( veteran, give name of wa,>
Sex.rlsr4dil r_Calor.iit: .4....or divorced wnte the word).. -)/..-- -� :Date of Death .! 7 y -2--- 19-C2
Age 7C �,e��ars ..Months ,pays Birthplace.. & Y� t�:t : "
Cause of Death`--6 -.2 i --: ..��.24170- L �.�.."1: '7 X ,
Certificate was signed ,by . Z4L ... :ram_ :....al......�% c. M.D.
Address / i.. . �`
Place of Burial (or Removal) 4...,---z--Z--'C-
(If body Is to be temporaril held f11 in space later) _
Cemetery...t.a r v77 ..� � Lk.... Date of Burial / 19..•Y". 7
(If body Is to be tempura ly he d,fill in space later)
The Certificate of Den containing the above s ted 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
Num ,and pnnm�the ba is thereef/I HEREBY GRANT A PERMIT", 7
to... Z GAL J'. .y --� 'z'e" - i� � ,� / �I
.Name) (Address)
the �. . lri,T hold ten:por y and........_-2-7L:L the body.
( rtaker or pe Paring ebarge g-eor ) (Inte^ remor or her/rise(Minos.)of[state bow])
Dated.... . 49 --t' 19...}...7 (Signed- .???7���' ... .. /M rerG-r �L�-
/// al Registrar
• Permit is sufficient for the Removal (and Interment or Creme ion) of a y to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which cas a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE ia!
c.-o.,-'e-t.,..62. ,
Date Q#%r/2 'L?� - waste.- dA, . -9 19 V
(iabiYsan et or Cre tion)
_.
(Name of Cemetery, Crematorium, etc.
Sectio ✓!, ✓Lot N . Grave No.q
(Signed) 72: Vee-)-€.-( (/
(Person in cha
Address ( ./IL h6_,,„-{
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 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.