Smith, Maude Form vs.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or subrsgistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE SLACK INK. Town Registered No.�.:/4'........._
Village
Dist. No County... — ..
.,. ,,���:� or City
(It city, give street address)
Name of deceased -71_
- Veteran
j, (If veteran, give name of War)
/a/te Single, married, widowed, � , .
Sex Color.,i„F or divorced (wnte the word) Date of Death 19
Age Years Months......................Days Birthplace 7,(
Cause of Death '' ' -,-h,:1 yY2t.,,
Certificate was signed by `,,,e M.D.
Address
Place of Burial (or Removal) r t
(If body is to be temporarily held,fill in space later) /
Cemetery Date of Burial ,l..;,z 19....5. .
(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, and on the basis thereof I HEREBY GRANT A PERMIT f�
to F/...L
(Name) (Address)
the k to hold temporarily and the body.
(Undertaker or person having charge of corpse) tInter,re ove, goose of(scats bowl)
Dated u1;c.r.......L.......19 (Signed). ., , . .... .... .. . ...:sir),..ei R.is
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation of a body to any pert of the State (mitiect to local
ea:rotary or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
e_ex Qom.
ENDORSEWINT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date oi�.l7�t � was 19 /�f
(Inent or )
V72 ------7-----
(Name of Cemete , remstorium, eta!)
Section Lot No.J7/O Grave No.
(Signed) ��- . ��r
(Person in charge)
Address
V4c
Person in charge mast return this Perm
the Registrar of his District within SEVEN (7)( )
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE
RENT, write across the face of the Permit th;; 1.ordc
"No person in charge," and FILE PERMIT WITHIN THREE
(8) 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.