Hall, Ethel Farm VS.sl.
NEW YORK STATE DEPARTMENT OF HEALTH / 4,5
OFFICIAL BURIAL (OR REMOVAL) PERMIT
car This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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 Z. C 7 County...lr0 4'"41 .. or City g.,,,e,'`""''`�
�i (If city, give st t address)
Name of deceased �"�' ii - " C�Cf .. Veteran
,, Single, married, widowed, (If vete sire name of War)
Sex.J IG-: 4: .,Color..� .. ...or divorced (waste the word) -tfli:.-i4c- ':: `7'
Date of Death. ,
19
Age i- -7 Years Months Days Birthplace..1 4 :Zx.-e. r. : C.... .t.•..2• f',
Cause of Death Ca-`-1;-��� Yy. . Z... ..
Certificate was signed by . .... ..i .. .. M.D.
Address '7 I `` ``�if .. .....I cy1,-4 .�-1r4 .�. . .
Place of Burial (or Removal) �'� z—t� —c t--C---
(If body is to be temporarily held,fill in space later) —
Cemetery .co... .K.�....1..... •• Date of Burial 19
(If body is to be temporarily held,(fill in space later)
The Certificate of Death containing the above sated 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
Numr,and on.the thereof I IAERE'BY GRANT A PERMIT
to beL "L.r..w 1 �.r..s{..1/.tCA! /�,L : �. , /,
— L/ ,
/ (Name) "(Address)
the . —4 Sr:. .... JL-1-4 to ld temporarily and 2.:."� 2�� the body.
(U dertaker- rson having charge of corpse) (Inter,rem ve;a%nt rise di letate howl)
Dated....� �` 19 Si ed �� ` • 'ti
( ) :�/ Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Seats (subject to local
cemetery or other regulations), unless removal is by common earner, in which case • Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX'IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o " ' -! wa3 dT L3 7
(Interment or Creme on)
•
(Name of Cemetery, Crematorium, etc.
Section 6- Lot No. b �l 3 Grave No. --
(Signed). L2a�,i... c.„ _�8�8ilL
(Person i, charge)
Address VU ��'�d �
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 cords
"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 trr a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THA., FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.