Beecher, Charlotte Form vs.IL NEW YORK STATE DLPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
it This Permit can be aimed 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.—.._...._........_
111i `a
Dist. No..k. County...... ::`3?. ,'� or Cityy �- 'vN
`_ \ ` — (If cit), aloe str t address)
Name of decease V\.--4. .r,,..l..0.'W l M-Ct-� .--`l Veteran
Single, married, widowed, (If veteran. give name of w..2,_
Sex Color U.)...or divorced (write the word) `— '.AA • Dat of f_D b >... 19�
Age .2-.. Years. Months Days Birthpl ,
Cause of Death, . .?z4.` ) .. .r�••• N.-
Certificate was s' d by ..... . ...°b..- .�� 0,,,17 ,,.... ... M.D.
Addre
Place of Burial (or Removal) . -V\'A
(If body la re mporarily Id,ell space later) ��
Cemeteryl..3 �a.JLl... Date of Burial t G :..[ . *--1 IV
(If body is to be temporarily held, 1 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 cal Record with the above stated Registered
44.,ber, on the basis th� I HEREBY NT A PERM
t, ` (Name) •�•-•�� Address
the... I ( to hold ten 'ly and.tti.J.32" , thy.
•dertaker or vion ha rig charge Af corpse) (Inter, remove, t se soos of[•
Dat .... .... .r. "Q' 'dam 19 (Signed ��"
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the 'fate (wbjeet to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is rewind.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of v was 1 . 2 7 19 J 7
(Interment or Cremation)
(Kane of Cemetery, Cremateriva, etc.)
Section /7 Lot No. ;5-9 Grave No.
(1.fr '
(Signed) a.G-?--P
'll (Person in charge)
Address '. v , (o a d 4¢-s-c- ` `e--
/ . ?-(7
Person in charge nest 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-
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.