Mulholland, Elizabeth Form VS.sL 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 acceptance of a CORRECT AND COMPLETE C IFIC E
DEATH, Y WRITTEN URABLE BLACK INK. Town Re stered � .
�+' ageemx�stel�d., N. •
Dist. o.9. QCounty.. Tor ftt9 v
;LI7AB.ETH 1y .MULriULLAtrD (If city, give streeMbldress)
�
Name of deceased Veteran
(If t ive name of War .
Female V�"�ilte Single, married, widowed, 'Tarried l et1l sx
Sex- Color or divorced (write the word) Date of pea ...e.r...B.a.-,, 4,T,. ..•,
Age19
9 Months,. a l ce
C Yeats o_ the ern'i WI th tag ' S
Cause of Death Purino
Certificate was signed by M.D.
Address
M'ear,ow'brook .o"'rit l.., i'1:"'t e•ado �1\I.`T•
Place of Burial (or Removal)
71e ri 'F aT1s , r.Y.
(If body is to be terupgrartly belt!,fill in,s ace later) 12/1/ ECB
Cemeteryi-ne View iew �1 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 F're ep c rt, =''T•y
to Chester A. Fulton
•
Und d k e ' I-' n to - (Address)
the to hold temporaril roto"'. ...the body.
(Undertaker or perlw Aaving charge o corpse) �•". . ".therwi = disoos•. , 'WI)
Dated m....rl 5 19...� .. (Signed)..
Removal Interment or Cremation) of a body to any past of the Slate ( • 'T'""'ocal
This Permit is sufficient for the (and
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) ' re .
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PRElII SES ON WHICH INTERMENTS OR CREATIONS
ARE MADE
c_ '--7 —Date of was' ( 19 -6 er
(Interment or Cremation)
%� `.-2...--..-...":4-e•-•e------H /, �Jl.i.--� �--�- _ c ice-{ �, /
(Name of Cemetery, Crematorium, etc.) l
Section.-AZ ( Lot No. Grave No.
`4
raon in charge)
(
Address ' �
z� G 71Ja+C- 2-4.--7
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 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.