Martin, Otis Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH #-- 17/F
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__._...._....._._.....__
Village
Dist. No - � or City`
eyYor city, gf a revs)
Na of de s ' .... ... 3 Veteran ... ..... ..
/ Q /i veteran, give � a War)
/��� �.I , married, wid.
Cae /,o f•� orced (waste the �� �... ... sa D . �� '.. . /,�..19�a
Age Years onth r/ pl =/ . ,
Cause of Death // �+' .' .-�' •
Certificate was signed by 1 /... . . .. -' . i M.D.
Address ° ... - .. - �... `���
Place Zle..(;)r a val) � / �� �j. � �Pl bodemra d,fill inCemet .. ... / / �. Date of Buria 1'4�/ 1 a
(If body is to be temporarily held,fill in space later) /
Ths 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 se same for registration, have recorded it in :i, Local Re •rd with the bove stated Registered
Nultf and o•As e y j the .f I HEREBY GRANT • P T
to...• i. / ws.+s.. //.. / ��� / i / �// ,�:0,'�� �� '�, •
the .. ! ...� to hold tempora '�d!-�. '7j o" i ! / the body.
• dertaker or • •n) ng charge of orpse) (Inter,remove,or otherwise disgoae of(state howl)
yt %���;,. ... ....
Dat .. . / /. i9. (Signed)
/ Local Registrar�L-
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the (eubje t to
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. ) is Z
s
ENDORSEMENT OF SEA`ION OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
s' � ,e
Date
.� �L ✓ wa C 19
(In terraer.t oT 'p'IW 44 e.)
(Name of Come tery, Crematorium, etc.)
Sect:_on 7 Lot No. 1 325 Grave No.
1
✓ (Person in charge) �j��
AddreSS p � Li �� '���7��
iv ;21-7a4),
Person in charge must return this Pe rmIt 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.