Hart, Marie Form vs.si. NEW YORK STATE DEPARTMENT OF HEALTH
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 DURABLE BLACK INK. Town Registered No._.4 .:Y`Q_
Village
Dist. No 561.11.County..._.... WA=AG or City 0-1.erlA .F..&17..a.8
(If city,give street address)
Name of deceased Marie C. Hart Veteran N.a
F w Single, married, widowed, (If veteran, give name of War)
57
Sex Color or divorced (wntt the word) Mar.XUP., Date of Death 1.1/16./ 19
Age 3.9 Years Months Days Birthplace Gie.na...Fa11s.,...N......Y.
Cause of Death .ar.c.j.rl4ma..of...c.ervii:.x...ut.sni
Certificate was signed by Harry M. DePan M.D.
Address. ( Lens...F&i•1.s. ... ,
Place of Burial (or Removal) Town of Q),}eP 0,l jy,ry,i , M. ...,.. ,,
(If body is to be temporarily held.fill In space late
Cemetery llt• A ,phonsus Cem. Date of Burial 11/19 19 57
(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
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to JarrA ...F.,....S.ing1etan Gl@-.a F'ala..S.,....N.....Y...
(Name) (Address)
the UndQrtiakIrr to hold temporarily a p.• the body.
(Undertaker or pp�� a acing charge of corpse) e,,r e, r o se dish of(state bowl)
Dated �)-/1 .f 19....5.7. (Signed)
cal mistral.
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (object to local
cemetery or other regulations),unless remain/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 INTERMENTS OR CREMATIONS
ARE MADE
Date o -1...z was ✓to—c' / 7 19 f 7
(Interment or Cremation)
di.
(Name of ceme ry, Crematorium, etc.)
Sectio�i�� J t No. oZ Grave No.
v a:Lc.") ,,, ,..r) /
(Signed)
(parson in charge) �.
Address iJ Q A� yt 6 a a _ '�.�- b ,
Person in charge oust 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 (RUST 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.