Trasburger, Baby Girl Form VS_el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 DURABLE BLACK INK. Town �1 Registered No.__./.
h li&: . -
VillageDist. Nos-11 County.. or City :-?
(If city, give street address)
Name of deceased 10.(- .. ........... . • ,. -../._,'Z ... , Veteran
Sin le, married, widowed, (If veteran. ire name of Wu)
.. ... .....19 r
Sex � Color or divorced (write the word) Date of De
Age Years Months »..Days -, Birthplace '.' �' ``. �'�
Cause of Death A ` -- ..
�tirZ. -
Certificate was signed by o M.D.
Address . cam .. ...2........ ...1.,,
Place of Burial (or Removal) S.:f.. .. 7 ti-a.�,:c'.... �7�y• *�: �Z �.•�e-g/G
(If body Is to be tg porarily h I ,.fill In space later) t r
Cemetery.....:�.Ea... . ..."..v Date of rial (`(/ 19..)..
(If body 11 to be temporarily lald,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
Number, -on, the basis therjspf I HEREBY REBY GRANT A PERMIT ��
to ...1\.I ae.4.i.V— ,/ I .1.lr�ri�:Y :GIi............._... `S+ -—Q�`-- .r
/� me
'a f
the to hold temporarily a �:.. he body.
(Unde e pe7n having charge orpse) r re Ye,o diegose state bo )
Dated .Y 19. (Signed)
/ Local
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which cast a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMH'TS OR CREMATIONS
ARE MADE
Date of _- _ ' =�---was :c >. / ! 19 17
."2" (Interment or Crenetfon)
V F ailig-i-ttat -qe--- -41
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 00244 0.2..t...9 �Gt�'
( rem, in cha ge)
7:, e d oAddress ., o, /, '1'
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.