Ramsey, Florence Form y&aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
s:' 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 Registered No.__ f.::3
Dist. No.... . , .�. Village ../, J�
C/County. .. ! 2:Y.. L., or City . 'I/.4.= '-.Y e- :"
1 (If city, give street address)
Name of deceased `-7 :Y. :1x,:r......... al ....ea.r.,..,.. Veteran ` —7
1 Single, married, widowed, (If veteran. give name of w.�>
Sex `4/ Color.h or divorced (wnte the word)..... .. ..CE-rnx. Date of .ath f 19 ,
Age 3...3 Years /y Months Days,, Birthplace. i7kkz- a:cc w-e, G4...1..LV..- ,
Cause of Death .G...;Gz�: es‘i.rc, a,,, P<%Z ..-2:?:k- �:s.-a-1,,
Certificate was signed by ,l3.. v „- yv- M.D.
Address
Place of Burial (or Removal) Z } .
,,,4,,..
(If body is to be tam rarity 1d�ll to s e later)
Cemetery G .. 4f? -I.cra.,C, ,,rj Date of Burial de.d.e:t .. 19.:�.
(If body la to be temporarily bet 11 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
Nuznbersod on the basis,t�hem�of I IjER BY GRANT A PERMIT �/� ,^
to :Z l:L..a,.a.. ✓ f C� .t.ac.k '�,a ,`� 'ee-L " )2 .7,
the (Address).�.,.- to hold temporarily and �.. . ..the body.
(Undertaker or person having charge of corpse) (Inte r ore,or of an f state wl)
Dated C.,../ 7 19...4:7 (Signed) ,f
// Local
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert 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 Ii i 'TS OR CREMATIONS
ARE MADE
i
-7
Date of tc j .. <, -- was ;1-4-�^- -- 7 19 t5 /
(Interment or Cremation)
(Name'of Cemeter3, Crematorium, etc.)
I
Section Tot No. Grave No.
i
(Signed) .
Z6) „,.../ a.„/u,L,
(Person in charge)
/�, ,` G
Address / i)
/�� AA
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no j{erson 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," aid FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relati e to the return of permits
are liable to a penalty f NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DO FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, ti
report violations thereof.