Martineau, Lena Form vs.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit tan be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Teem
Village, or City) in which the death occurred alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE Of.
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No—st7...6...3........_
7;
Dist No L.1.-‘.0:1 County.- +.--zzrazi..d./, -4: Village
or City
r‘K'.. . ....s. 2:-/..../67:7-td...12..-4.4.....0-4-4-,-
.....CC,„ (If city, give street address)
Name of deceased
Veteran -1-6-e----
(II v ran.
u, Single, married, widowed, c--, give name of War)
--• \
Sex "‘17 Color. /1 or divorced (write the word) '--' Date of l' ajli .F- 19..S.
Age.. 7 e Years. Months ... .... .Days Birthplace i2" . . . .7.4.111:e.;.).").:..
Cause of Death
Years.,.,
7 . cg__,,,,,(........... a
Certificate was signed by ..4d •
' .3X...-... M.D.
Address. ZhL.Ce.--..i ly ,
Place of Burial (or Removal)
(If body Is to be terni :.2 held,fit1 c;later)
6 i
x 7
Cemetery t.-27.2zra.4v...... -/-z4 Date of BuriaI .. ):-..e..44...,,, /./ 19 '5-7
(If body is to be temporarily held,II 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, haç recorded it in my Local Record with the above stated Registered
Num. and on the basis t1eyef I HERE Y)GRANT A PERMIT d ,1-1z_, )9 •;-/
to - A,- .,..... . ..
7 ,L.7,'? ".6.. . 7. . 4.... ----tA Address)
the. 1
LI _..v..... to hold temporarily and.. .,-- '- the body.
(Under er or pe n having charge of corpse) emce or e dispose (stets how))
Dated // 19. ..7 (Signed) 7/
Local seistrar
This rmit is sifIclant for the Removal (and Interment or Cremation) of a body to any part of the State (lobject 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 PER90N IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of ' g was L�l'' 19 ��
(Int6r(�ent
•
/( �r'tz •cam .� ..� ,
(Mame of C tery, Crematorium, etc.)
Section Lot No. Grave No. /
(Signed)'/ ;� _ ,),-(1_2(
(person In crime)
Address • U • � G D U
Person in charge Host return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
RENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAIS 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.