Muller, Mary Form VS.111. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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 RegisZNo—
Dist. Ne(1(1A..e.tounty.. .../k...4..........
(If city,give street address)
Name of deceased.
Lt
Sex...... ..../i.i.. olor Single, marrie widowed, )//,,,6/
f or divorced (wnte the word . : . . Date of (If ypapiye name of War) 4
--e
Age i YekrA000 Months j irthplace2
Cause of Death TIQ 62- 7.--01---/-1.-- Cz / .....,,,j
Certificate was signed b 7.").:/( --e___. ,,,,,, m.D.
Address el ,
Place of Burial m r Re va ) -e-.. --C 7 /-----e---€ --- 7
(If body is to Id 11 space later) P,71
Cemetery .. ... ../ . . . . . . ..... . .:-.-124-C---1:7 Date of Burial 19'.(It
-
(If body is to be temporarily l d,1111 in space later)
The Certificate of Dea 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 f r registration, have ecorded it in my Local Record with the above stated Registered
Nut ,and on ,Ileerss. erect REBY /RANT A PERMIU
4,t1:1
•'-i ') ,, ,,,,
to... -1,•.. Le. ...-..- ,t .,:t4A, - ,,.-.-- ,0 , -- 16.0,,e,..a7
(Name) (Address)
the to hold tempo '1 body.
Dated
("te IIc, person baying cbia9rge3.e7e) r,remo ,or othe711119(mose o [eta bo
(Signed) .. ... . • • •• •• —
Local Regirtrar
This Permit is sufficient for the Removal (and Interment or Cremation) o a y to any part of the State (subject local
cemetery or other regulations),unless removal is by common carrier, in which can Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMITS OR CREMATIONS
ARE MADE
Date of - "� was 19 J�
(Interment or Cremation)
, -,.' i,......01/(R41A-4--‘4---
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) U' - I ,9 j66„‹�-
(Person in charge)AddreSS Y.. 1 C �� ///�/�/✓ ,
I
Person in charge waist 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, ;Trite 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.