Fuller, Emily Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr This Permit cams 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 CERTIF!..C...T OF
DEATH, LEGIBLY WRITTEN IN D RABLE BLACK INK Town Registered No._...._..
try Village
Dist. No Co or City
• (If city, give street address)
Name of deceased .... ... ..... . .... Veteran
d, f veteran, give name of War) _�'
Sex. Colo Sinor diglvorce, arri ed (edwnte, widowe
the wo�d�z%r/�'=a Date of Dea9 . _ /6- 19- O
Age Ye s.... Months Day Bi place -
Cause of Death_... e �
Certificate was signed by.... ... '�
v .„ M.D
Address.
Place of Burial (or Removal O „ :
(If body-is to be,_ orarlly el , -in space r) / (/
Cemetery.. lug..... . �w !��
- - Date of Burial / ci— 19sr
(If body is to be temporarily held,till 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 Reco wi the a ve stated R gistered
Number on the basis t ereof I HEREBY GRANT A PERMIT
to
) (Address)
the to hold temporarily and... the only.
(II ertaker or person haying charge of congas) (Inter, move rvaise ys a Low])
Dated. j 19......r. .4 (Signed).. .... �J
((((((//////`` Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y 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.
-/L2-CG6 ' -
ENDORSEMENT OF SE1TON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CRE(NATIONS
ARE MADE
Date9f G .was_ 19�
(Interment--or Creme di%)
(Name o Cemetery, Crematoriu , etc.)
Section Lot No. Grave No.
✓ r � n
(Signed) �� % C -
(Person in charge)
Address �� 2 _� �
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
frcar, 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.