Stafford, Eleanor Form VS.SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 FILING and aecgtaace of a CORRECT AND COMPLETE CERTIFICAT OF
DEATH, LEGIBLY WRITTEN IN DURABLE SLACK INK. Town Registered No—Z. q_CERTIFICATE,
Village
Dist. No. lr./. ...County..... �` or City ? " ���G �:, ,' �
r
(If city,give street(ddress)
Name of deceased.. a.4.- -a--' '' ,..:? " Veteran
Single, married, widowed, - (►( veteran'
site name of War)
Sex !J Color...<4 or divorced (write the word).. . .. . ....,..... Date of Death G 19
Age i •'...< Years , Months ............Days Birthplace i
Cause of Death '),I..i -�- 4-x—= 7i ..., �i ``�C
Certificate was signs by.�..`J .. 7�, �. M.D.
Address � � "7 e� `- ,.,.....
Place of Burial (or Removal) ---e---- -Le —
(If body is to be temporarily held, fill in space later) -. __ _
Cemetery ,;.! t.� ��..: �� Date of Burial � o �d 19.J.
(If body is to be temporarily held, fill in space later) I
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, and o,th,/basis I.thereof I HEREBY GRANT A PERMIT( -7 / i<
(Name) �� s' (�ddt*ss)
the �� �' ~r to hold tempo ri<y and the body.
ndertaker or person having charge of corpse) (Inter, mor o4gadse nose of [state how))
Dated.. ........ .. 19 (Signed) ...
Local Bsglstrar
This Permit is sufficient for the Removal (and Interment or Cremati of a body to any part of the State (*abject to local
cerrotery or other regulations), unless removal is by common carrier, in which we a Transit Permit (VS No. 62) is required.
AL.t. �1
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of , 1' C 1..,•� .f was ti.c_. /0 19 t.
(Interment or On)
/ (-7
•
(Name of Cemetery, Crematorium, etc.) J
Section 6 Lot No. 4 9 / Grave No. 7
/
(Signed)
(Person in charge)
Address 6 F 4 I/..� /41
� 2f
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 fiords
"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.