Hall, Laura Form VS.IL NEW YORK STATE DLPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gr Thu 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 • CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK.INK.
Town Registered No—.._...._........_
Village i e/ .
Dist. No :3‘L....County.....,7, '-2 -- or City �`Q
�/ (If etty,give street address)
Name of deceased -�4- el. 1I Veteran
4- I , / Single, married, widowed, ,, A (If ♦ teran, give name of War)
Sex ' Color `� or divorced (write the word) �' + ( Date of Death. . . J 19
Age _ '' Years Months Days Birthplace ...... .... . ... .. ...
Cause of Death ` e
Certificate was signed by... ... ..../.)1:4 v .. M.D.
Address i1 G�hnnlr3Fal. . ..Alett "
Place of Burial (or Removal) if-v�k.....lJi.I.CaM� eA-�' .I
(It body is to be temposarily held,fill is cs later)
Cemetery ( (rstt-i .... Date of Burial t-' 19
(If body L to be temporarily held,)II in apace later;
The Certificate of Death containing the abov 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
Numbe& on the asis t to tk4A4.41.4144 M.. tr7f I HEREBY GRANT A PERMIT �('-. ^ �(�'
(Name) Address)
the to hold temporarily and the body.
(Undertaker or person having charge of corpse) f , , (Inter rem e,or othe di/moss o! [state Low))
C.='- > " :,, may,
Dated 19 (Signed) .. . .. . ,., � ...... ..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (w`jeet to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No, ti2) is required.
Cid-iat.. (---3-1 T
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISFS ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
C_.
Date C-----
was 5P 19/yc
(Interment or on)
Lii:-/;i1
..-.2L,
7:Z/
emetery, Crematorium, t �-�i�%L�
Section _ Lot No. w 4/ Grave No. Z
r /
(Signed) f�' Y✓ C ,l.��i
(Person In charge)
i
Address 11` •L`'
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-
TENT, 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 OFFLNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.