Monico, Madaline Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH j g-G'`�
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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. No3- G� .County.... !�..��:, '?: (�4r
or City , L2-z. /Wr-&•
(If city, give street address)
Name of deceased � „a,-a 4--e4,--,Le . / 7-2??'l -ei Veteranveteran,;4-
ff Ingle, married, widowed, (If veteran, live name of War)
Sex ,. Color.. .f.'. '. : r divorced (wnte the word).. � Date of Dea 4/)--% 19. ...7
Age 3. Y rs Mon Birthpl .41✓. L ,,�'=-t
Cause of Death Months.
Days 4� CiJr1e ,r �, :. ?. �/ �..yf
4 c,,G.!..Zc .
Certificate was signed by ' r e- ct�� M.D.
Address
Place of Burial (or Removal) �d.1i. ...., 1.... 2/..,c„e.4. z,: .•. •••.• ..,, ,,,,,. j 3/,
(If body 1s to be tempor d,fill in space litter) _,7
Cemetery �...d. i.... 2 :. ...— r 41 • Date of Burial `.�. ../...1 19 /
(If body 1s to be tempor ly held, 811 in space later)
Tht;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, on a basis thereof I(*IEREBY GRANT A PERMIT
to � x �.. .: :: : . ' �:c� .... �- G
(Address) 1
/�_ `j the � � • :s„{ � to hold temporarily and the body.
(Undertaker or a having chars°of corpse) (Inter,rem or otht se o [state wI)
Dated / 19. 7 (Signed)
/ Local R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sabj.et 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 INTFI1MENTS OR CREMATIONS
ARE MADE �,CCc-- Le
` I�
Date.9e'�Z �i _wad " /'7iL / 19 (37
(Interelent or Cress )
(17,:::6_,.,
(Neese of Cemetery, Creme toeing', et.a )
. - - .(.
Section Lot No. Grave No. —
(Si wed) �l L+°/`j�r�'`_ ,�l�/.,�^�4
(Person in charge)
Address " 1 G 2 /CMG ,, /"
-?
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.