Murphy, Estelle Form TEL SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit can be signed ealy by the Local Registrar (Deputy or subresiatrar) 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.__.._...._........._
Village
Dist. No County or City
(If city, give street address)
Name of deceased Veteran
Single, married, widowed, /I� (If veteran. give name of War)
Sex Color or divorced (wnte the word) /4'...:4.,; Date of Death 19
Age Years Months Days Birthplace
Cause of Death
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial 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, and on the basis thereof I HEREBY GRANT A PERMIT - i. /` ( i
to
(Name) (Address)
the to hold tempo rily and the body.
(undertaker or person haying charge of corpse) • (Inter:remo , oth nose of[state howl)
Dated 19 (Signed .. . .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Creme n) of a body to say past of the State (subject to local
cexretery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
Cleit.o-C—# C-L-Lt1)162(Li.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTE[MENTS OR CREMATIONS
ARE MADE
Date c 277 was 1-IA -2- 19//
Irate nt or,
//)/...-5 '2./4( C-/ 1------7-----
(Name ofCemetery, Crematorium, etc.)
Section 3f
Lot NJ ' / Grave No. t
r ( r
(Signed) ✓l ��-. �
(Person in charge)
Address ( Q.��� =Ct� JJY
‘ e
, ' ‘ "Q--,‘4 7g,
Person in charge Dust return this Permit to
the Registrar of his District within SEVEN (7) DAY
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.