Jenkins, Florence Form TEL 6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gr This Permit can be signed wily Isy the Lecal 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
or/, CityVillage //
Dist. No....1.C.L.County..........e.....a..12nie-
(If city, give street address)
Name of deceased ' ..1..i- --C-2-7..e.P.....,2.-. f Q.a- . .,,, Veteran ---7.---e..-t
•...._ . (If ran. give name of War)
//,...- Single, married, widowed, 9
Sex '- Colori/ or divorced (write the word). 1. 1.../..rail,cft Date of Death ‘,./...A.aa.4....:4....19. TcP.,
Age 15-7 Year ,-, Months ._...Days t7/ Birthplace , , i . 7r.-..4.-2.1., !..i. .,
Cause of Death L....t. i...--14 4.4 4.-ka.-47.4, -<",.-44. .="71. .... \is sj
Certificate was signed by .1.</ 7.4r, .'''‘.4.6a ....4:iata M.D.
Za .7Address as loc.".....E.e. . r,,,. 9... _ _
Place of Burial (or Removal) 7-6:2(0-1.2 7,-;Th..--1-,....c../.{.,4141-2.. q7 1
(If body is to be temporarily held, fill In!MIN latm)
Cemetery A...-....t..-4 Date of Burial /.,,4 :d.e.cr- 19 LP
(If body is to be te orarily 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
Numbertied on the basis thereof I HEREBY GRANT A PERMIT : )
to .6.A.2...4:A.CvV...'1 ._....07( .14.. ' &(i' 7
'.0 c' rV
_ (address)
the Name
A &•s-le )1 ' —4,, to hold tempor rily and. ..e. -- the body.
(Undert4r or person baying charge of corpse) ,(Inter, mo dispose of[state bow])
19 (Signed)
Local Registrar
Registrar '
. ,
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert ef the State (eubject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
n
CQ,
551/4,1_14.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o 2 7 s I was 19 �
��(Interment or )
Ae
•
of Cemetery, Crematorium, etc.)!
_.,....9.--...-
Section Lot No. Grave No.-----
(Signed) .gl-22 'G ��----VG�var
(% son in charge)
Address ‘ / A�it / . -
�� - -'Z%'�—/�
:-
Y �
Person in charge nest return this Permit y
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.