Burnham, Elva Form VS.a_ NEW YORK STATE DEPARTMENT OF HEALTH , ri
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ur 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 FLUNG and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town istered No._
s, Village �.
Dist. No...�;1'�= ' County.....Yd -----/r2-e--r-c__ or City 4 �/�
(If city, give street address)
Name of deceased 4.-- 342-71---34g- -fr)^--' Veteran
�7 Single, marrie owed, (I( veteran. give name of War)
Sex . Color or divorced (write the word) Date of Death 7-- • 7- 19 -3-7
Age Years Months ..Days Birthplace
Cause of Death
Certificate was signed by — M.D.
Address
Place of Buria (or Re -ioval) \�
(If body Ss to be por rild,fill in space I )
Cemetery :ki uit -' :,y, Date of Burial // , 19 i
(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 r ' ration, have recorded it in my Local Record with the above stated Registered
Nu ' and on the basis I. EBY GRANT A PERMIT
MO
,� :..
the • Ki azLc-c �T `?mac (
to hold temporarily an . .. the body.
(Undertaker or raving charge of corpse) (I mole, of ose of[s bowl)
Dated 5/ / 19.5 9 (Signed)
R
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 INTERMENTS OR CRENAT.ION
ARE MADE C y(C,(/„ly C1 •-a.L'
L--
Y
Date o r0/ C94 was - 3 19 C-5 7
(Interment or Cremation)
ZCZ -----?—
44�i
(Noe of Cemetery, Crematorium, etc.)
Section I Lot No. '� Grave No. _
(Si fined),�Z .;767.--2,e46--:- _---- �' ""�P
(person in charge)
CCu �- /y
adai�ss�, �o�;
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
frown 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 wards
"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.