Liddell, Lauren Form VS IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
£ 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. `---)
V-./. 9.Dist. No... . ... ...County. se /c...- Village "--
- or City 4-17-(- -1-
Name of deceased free," (at.h;-<•-, (-ej.e€' ,,,6 (If city,give Street address)
Veteran )7--- ---)
Single, married, widowed, (If v ran, give name of W.:)
Sexentg. ...Color.glii&Z' or divorced (wnte the word).4eaf-4€/ Date of Death. ; 2‘ 19 -rer
Age 7 Years ...Month _Ai.3 7z,, _ 3044:14pli,ac zetil -eleeee_i_e:c.ez,
Cause of Death (:?-1-11-'4( 4,-.V.- `*". y
Certificate was signed by et-aZ. M.D.
Address ,...40.1.7 t&-/ .& h
Place of Burial (or Removal) 44:irair-"'
(If body is to be tewrgarily held,44 in,ewe la )
Cemetery -,,'---Z.tt..-P r;-1.-el."‘j Date of Burial.. .,. .2 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 11/0.Ord with the above stated gistered
Number, -and on the has' thereof I HEREBY GRANT A PERMIT
to .10.f.7-44/ ... . ./. .a.e.: ,.-.t..
azfy_
(Name) • •
._.- , (Address)
the '61-"Xe"6: ‘-e.k.) to hold temporarily an ore---7/...- -- the body.
(Undertaker or person haring charge of corpse) ter,remove.or otheggAse disnon,of[state how
Dated ,,,.„... yr 9 i 19. 4'1: (Signed) .c.. . ..;r4`.-k.et:4"...i.-:.- ---"-'-'- ;";----.!...,f.1--..e;.:-.- '''--
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
71 C"
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREIJATIONS
ARE MADE
Date o /.`�"7 "-�1� �.
was ( .�. / / ig ilj
(Interment or Cremation)(11 )117'" 1". '27 (--/ ----/---.
._.....,.„, ,
67
(Name of Cemetery, Crematorium, etc.)
Section 2---)."' Lot No. `'7 d Grave No3 "
(Signed) /7 �i z� ;.,
(Person in charge)
Address �' [� `?yiy,. `.-e
. --. �
Person in charge oust 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 Lords
"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.