Dolan, Mae Form is.U. 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..- �.. :.1.?._.....-_
�j Village /,
Dist. No 0 Cal County.. ..�`P.��!rr'--�' or City iC� 4�
• (If city, give street address)
Name of deceased ,� ge,... %� 1� `r�C.�s..r Zre,c4.1-f..., Veteran 2 -l"
Single, married, widowed, L (if veteran. give name of War)
Sex ,,Color....,1 or divorced (wnte the word)...L &-n:z:e---,/.Date of De th ‘5 L.r �19.5..t
Age ,T Years.. Months ,. ........Days ' I it thplace ‘..:.e. •'...:4f
Cause of Death.- . . -..
Certificate was signed b ,� . - 77� a _ - M.D.
Address ,!.% 1
Place of Burial (• ' -moval) � 27 �.-0. - ..,
(If body 1s to bete".. �r held,fill in�s ace later) O /
i ,--' ��urial 0.4 19.. .�Cemetery �"�`--e- ,dl�� C ��� Date B
(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
Numbernii thQQe basis ereof/ HEREBY GRANT A PERMIT > /
to �eza-r�'Tl.....4 a..sii€.:i.....-r.. - e��r .
(Address)
the to hold tempo rily and.... ',„ :2. . the body.
(Undertaker or a having charge of corpse) Mite rem v` r se dianoee of[state bow])
Dated j/...2.. 19.J:.? (Signed
Local Registrar
This Permit as sufficient for the Removal (and Interment or Cremati n) of a body to any peat of the Slate (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS.OR CREMATIONS
ARE MADE
""-c
�
Date o 1���'7,31— warn / 1905
(Interment or Brewni,. )
/1)
ache o Cemetery, rematorium, etc )
1A74-
Section (0 Lot No 7/C Grave No.
(Signed)
fi
• (Person in charge)
Address,
Person in charge anist return this Permit to
the Registrar of his District within SEVEN (7) DAYS
frcnn 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.