Eddy, Maude NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. G6
ll,� ,) Town, Villag ZszZrelt.
I
Dist. No.21G Co ty Z'l161/1/14.--- or City
(If city ive'stre t ad ress)
Name of dece d Veteran
[ (If veteran, give name of War)
Single, married, widowe , 6 ,
Sex or divorced (write the word) ate of De / 19 ....,?, `
Age rs Month , x FDays birthplace..1/ -
Y.
Cause Death .. `....G. ..... .. c.<`�:.° lb>... ..., .. .
Certificate v'v s signed by {4vt- M.D.
Addressk i , ��
Place of Buri (or Removal) ....
(If body is CO e mporartly, ld, i space ter) >/
Cemetery ...:.. . ....,�,t�Z.. Date of Burial � 'll 19 ,�f'
(If body is to he temporarily a d, fi ins ace at
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same . .p-.ring to be MPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion have orded t in my Local Record with the above stated Regist ed Number, and on the basis th eof I HEREBY GRANT A
P MIT
(Name - (?,caress)
the .. . to hold temporarily and , the body
( nderta er or p n aving charge of copse) Inter, emove, or otherwise dispose of (state how))
Dated -,tG 19 ..: (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a bo to any part of the State subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit ermit (VS No. 62) is required.
1.'OItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o Z ih 1,4 was 'Viz/ 19
(Interment or Cremation)
r
L£ %lll ��
(Name of Cemetery, CrCrtmcfecurttrrr
Section Lot No. Grave No.
`rL
47-r:
(Signed)
(Person in Charge)
Address �t C I`
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, 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 required, under
penalty, to report violations thereof.