Nailor, Mary Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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.._..._'I.._.,�..-.0.........
,• Village �Qf
Dist. No J '' f County......, f..4,.' '�L- or City /✓ Y,e -/CO....(--(—,'
(If city, give street address)
Name of deceased 27,*-T'`-- /9 7a.'�� Veteran ,
Single, married, widowed, (If veteran, sive name of War)
Sex.. . Color # or divorced (write the word) Date of Death(
eath /�Y/ l ...19..
.&� / dt t, e a4 c
Age 7, Years ,. onu s.. .......Days Birthplace k �.... . . 7-
.. ... ......
Cause of Death 7c. .. ... .... ........ :ram.:.. f
Certificate was signed by a:. ....?,din-- .2. Yds, M.D.
Address 4' �.. is G'�.0.•. . L-
Place of Burial (or Removal) Z- -z r .. a.,.a.a ) ! "
(If body la to be temporay9y held,fill In epOt later)
Cemetery a ..:?.. :-i.'. edi..d... &mac..' Date of Burial //�z-, Z 19 S
(If body Is to be temporarily bel 11 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
Number, on the basis thereof I HEREBY GRANT A PERMIT
to y�'�tn ::�L:?.::..1� /2ria-T 1:��� 7 ..�; :t.C... :.` �L.ct-...c>7 Y 7y /d t
/1 7 Maws.` ----
to (Address) //
the s lG,G �. ���"' hold tempor ly rid '� ,, the body.
(Underta er orpe having c arge of corpse) .' rater,re se,o of lrw a of [state how))
Dated // .,. 194` (Signed) �`%%�� ...
Local Retfatrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'fate (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 INTERMITS OR CATIONS
ARE MADE
Date of ,> ;i(.ti r was• '� L 19 4-
(Interment or Cremation)
\)� (k.
/,l
(Name of COmetery, Crematorium, etc.)...
Section Lot 7) Grave No.
(7)(Signed) CCU`
(Person in charge)
Address
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-
MENT, write across the face of the Permit the cords
"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.