Durken, Mary Form VS.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit tan be signed only by the Local Registrar (Deputy or aubregistrar) 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. Taw n
Registered No.__..= ..d.S'
Dist. No c.) `' .� Village ,/i" ��
Cotuity.. . .(= or City y = �. .... K:
7 (If city, glee street address)
Name of deceased G L/-i/%t..,r1../ {„4, ,... .,, Veteran �'—
/�� —Single, married, widowed, (If veteran, give name of war)
Sex x Colori ':or divorced (wnte the word) / —� /Date of Dc.ath 6 / _ 19 S�
Age t G Year Months Days Birthplace.... -e- s.,. .y..
Cause of Death
"-'3----<-.-,L4:---A.-- C---*---e-- -si
Certificate was signed by e 'z-�z-- „ �/6—• M.D.
Addresss.x. ,...LJ..
Place of Burial (or Removal) T )7 g ' ... ,'., /f
(If body is to be to orarily he) 'fi in space 1at ) l
Cemetery "tt2 ,;" �t.r-.a.ere Date of" Burial -44.- 19
(If body is to be temporarily held, fill in apace 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
Numbers on the basis eroo,} REBY GRANT A PERMIT
to -K-:4
,� , f"" , i
) j il/-'''
the / kl'(- .!z4� E�� - (aaareaa
to hold temporarily and. the body.
(Undertaker or person having charge of corpse) ( moi5 r t e diaoos f[state howl)
Dated 19..t°5/ (Signed)
e1 Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which cue a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CATIONS
ARE MADE /-1rtd'_o !�,;ef't�'�e,
Date b f;''f./1-%'r''�.:_f was :'"-e--0 19 -'
(Intsrseatc-or Cretion)
'i,/,;(0"7-7 ek77;k •—
(::./.
-:7 75-77----1
"'(Name of Gene ery, Creieatoriim,Yetc.)
i`i -,
Section ' Lot No. Grave No.
(Signed?� i./.- /s--'
—!'-/--_ 2 ;.((/// '
(Person in share.)
7,1
Address "/ 4.) ' .�/ _j. (` _. -�
Person in charge rust return this Permit to ,e
the Registrar of his District within SEVEN (7) DA S
from 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.