Hillis, Ruth Borns vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
' This Permit cams 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 1 (If city Re *stered No—..5.7...5‘._.........
V-iitage
Dist. No.52eSZ.County...reeti.e.W42-W.. . or 9rt'Y -...i.,-..r...-e.. .r.,.. .S-e-‘
Name of deceased . i--(--z4- 7-- T- - , give street a ress)
Veteran
Single, married, widowed, L...7 .ezete;, (If veteran, give name of War)
divorced
SCX-72e-'1‘0,141:,r:Coloighe-4 or (wnte the word) Date ?f ea ‘ /7, 19 5$
Age. (P b Years o ths Days , Birthplac t.. .22
Cause of Death-14 . . - •$••••• • —
Certificate was signs y. .......... ..-:-.Z.-- , "W• M.D.
Address. --77-. - -41-V
'T
Place of Burial (or Removal) .,er-(If body body is to be teisplCiarily he pace later) ...8./
Cemetery /.4414d.W Date of Burial.ige-
(If body is to be temporarily held,fill space later)
Thg Certificate of Death containing the above s ted 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 th above stated Registered
_
Vi.54(if,4/A.
Num , and on the has' hereof I H Y GRANT A PER 7- - /---
to
( ,
the .....,:‘ ' 4f to hold teniporailyand ,....,-4.„-.4-,r..&,...--• the body.
grildertater 0%person having charge of corpse) (Inter,re e, r oa7se disnose of[state how])
Datediri.4(.4;a -1,.0- 2 19..4:4 (Signed)
,.7 4".: .
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a to any past of the State (mibject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
Gcg...e_.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CRIMATIONS
ARE MADE
• Date of ,. -.. `"'� wad; . 19��
(Interment or Cremation)
(Name of emetery, Crematorium, ete.)
Section Lot No. Grave No.
.
(Signed) ,��
(Person in charge)
Address
Person in charge must 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 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.