Fridley, Jane C"f—'-3 /YLi 6'
Form TEL C. NEW YORK STATE DEPARTMENT OF HEALTH Cl
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 D RABLE BLACK INK. Town Registered No. _._2-...
`�// Village /
Dist. No lh. O unty... . ....». . or City ' . .
// (If city, give street ad. es)
Name of deceased 92°44-4 0s.. ,,,Z Veteran
rJ Single, married, widowed, ( i give name of W.r) ,09
S .Co 0 f/� Gc .or divorced (write the word Date of eath� �.,....,,..19 S
Age..7 y Y ars Months7 Birth a
Cause of Death. Days �, „ „ „ ,,
4 I
Certificate was si ei,by.. c.. M.D.
Address .. . ...... r .
•
Place of Burial (or Removal) ., a ......!/ _5 — �, �,,,,4 •
(If body is to Wlem.porarily4,11 in space 1 r)
Cemetery..g7 u.c....4FD�/.. — _¢_,,,., .,.., • Date of Burial ...4e.4.., S y>, 19...i..
(If body is to be temporarily held,fill 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
Nu e basis th I HEREBY GRANT A PERMIT i �/t
to .. .... A )1rf -�i�j7�a
am
the to hold temporarily and the body.
Dated(U eats r or pereo having charge of corpse) ter,remove, r othetigp di no a of Isla ow]) y
7/ 19.1? (Signed) y
Tbis Permit is sufficient for the Removal Local> itfstsar
(and Interment or Crem on) o 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
Date _ QL/-,I, was �_.� lS 16,5
(interment or Creme tfon)
?/. 1/14_;: 7‘,4//71 L.
` (Name of Cemetery, Crematorium, tc.
Section Lot No. Grave No.
(Signed) ���� ,,. _.,........"....21%,,/V;2„/
, (Z._ .- ,
(Person in charge)
li
Address 1 kk At
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.