Pelkey, Baby Boy Form VS.St NEW YORK STATE DEPARTMENT OF HEALTH ; L ,77
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1 r This Permit can be signed only by dos Laical 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.._...,[..
. 6(.2.County..._. Village 7
Dist. No. .....���y�Y;Y..�v or City �.�.2��<xl.�.L...:jl 6-6r`2.
(If city,give street address)
Name of deceased e•-• �..6` �3 ' -e.-e'�� Veteran
Sex l /�J� Sin e, married; widowed, —/ C If veteran, give name of War) _
Co or•./:r or ivorced (waste the word) .4l.L....Date of Dea ? ' .. ..,../. ...19..a5
Ye
Age Months , �2ays. - � Birthplace...�./�.;,� l ,
Cause of Death-...Li, ! ,,,,, - C--- e y
Certificate was signe -Q:k''-e---r' M.D
Address j,�,� y
Place of Burial emoval) L.C?�:i- 2 ,,,.,R,e„e,., ,. �, , .,,
(If body fs to be to po Iy held,ellf space later) ,
Cemetery ..&-k.t. 4.;. "...4.4,- .C'4' Date of Burial 2/ // 19..ST 7
(If body le to be temporarily held,ell 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 �pj the,.basis the I HREB GRAN A PERMIT
to ..L it. .G�t. ...a.lt ' 1-44k..�c !( k- .(—. .c ,- 11.L. /e�'"'z'/ �i
J eri `leddress)
the (,�.- -Qx-- to hold temporari:y and...., ,.. the body.
(Undertaker oI~pe having eharge of corpse) (later, rem e,or otherwise dispose of louts bowl)
Dated Ci" // 19.S:7 (Signed) 7 r
Local Registrar
This Permit is fficient for the Removal (and Interment or Cremation) of a body to any pat of the State (subject 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 o f/Fr �x'�Z, iY�/( i -
(Interment oTL'riollPti
l� r r
(Name /// :. :2 :e ,
o metery emcteriue
r r etc/
sectio�: j C/� Grave Nc �'A
,
(Signed)� 4 �4 / Ct" G.,,
(Person in bYarse)
Address /ifZ,. 1f`-, -t %..--8�-,.A77a/L. ��/
(% "
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.