Linney, Isabelle Form a&IIL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Or This Permit avn 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 Registered No.�...a. ...
Village
.. t '
Dist. No `' (a County........�1 ..f:.z:?:�:�rc., or City ''�S;:alw �
•
(If city, give street address)
7 —
/
Name of deceased .:.,c�f.�. a'r�-�-- f`�k:�:k.� '�/-. . Veteran 1i1-
11gg 'Z 4-Single, married, widowed, --� _
Sex....(- Color...,,t.'lr. or divorced (wnte the word) i1 (If veteran. give name of War)
7'1---� Date of Death 7/2 19..:r...I
Age Y/ Years.....,} Months Days Birthplace -,✓ {< --1 L.9 �'7 41 p
Cause of Death............../..... ., ::Cr�a' NrL.n
Certificate was signed by �y- �? ..,, :f Via.. .....0 M.D.
Address .. . �.y.. �'
Place of Burial (or �.Removal) Lr:Zrtl.Y./.....Z... „4.ti,z4.42-7,.7... . .... ..r
(If body Is to be tempos Py held,fill n'pace later) / G
Cemetery i; a z: :......f:...c.. --K` 4 7.e , Date of Burial h,L...,a ( 19........
(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 registration, have recorded it in my Local Record with the above stated Registered
Number, op/ the basis/thereof I HEREBYdti GRANT A PERMIT
to € -. L.CrZs:k.c..:....C....... .. i.,,g,,..`"- l „-e, --?4-R � 4 4:::2 ..4 4
/
-dame) (Address)
.the 4. ..4.(::. Lc-- t---4-<'.Z� to hold tempos rily nd the body.
(Undertaker n having charge of corpse) (Inter,re , e, the s se of [state how])
Dated % .3.c 19... ..1Y (Signed) :..,- "/.=:- i.--e'-r-`- 'R
Local Registrar
This Permit s sufficient for the Removal (and Interment or Crematio of a body to any part of the Slats (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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&-.d17
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PRISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
-J Date o ' waste T92,6 ) 19 .�1-
(Interment or Cram.....' rxyr
''q,"7,;‘-- C,i
(Maras(1
of Cemetery, Crematorium, etc.)
3r/ /
Section Lot No. /(C Grave No. '
(Signed 7/ ,--. G (a7L �
(Person in charge)
Address /fl,t' j7 ,, i._
Person in charge Waist return this Permit toy
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.