Dufour, Hattie Form ITIL SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr 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 CERTIFI TE OF
DEATH, LEGIBLY WRITTEN/RV DURABLE BLACK INK. Town Registered No-___ _.............
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Dist. No.- ..ii...) 1 Coun ..."Z:,- .:;)‘..-- ,-.• el'-'--..41:-:." ..,,. c---, c -4.,
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1 ,, (If city,give street ad
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NameM deceased ', s,-,-",,Z. - -t- ,-.L :-'-- ..- -5.e. 2-----
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• .tek-Single, married, widowed give nam of War)
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s .. _ ,-/ eolorc.44 2,‘..a.or divorced (write the word)L"T.,'''C-c - ' '"Date of DaIl .,/ .7-/Z -- .,,,,,, 1 .,
Age.. , 9 Year i Konths ,.1.,,..- Da s --g 2 Birthplace
Cause orDeath.. ... .. ' - /.,,z4.-4, ::. _,,.‘"."'4:-,*
Certificate was signed by V, . - ". ' - 117-4C .-.6,, .D.
Address r Ci. t... . -1,4---z-e-.
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Place of Burial (or A oval), :r°-&4 .c..--( ' ' ,./.4--?-rLet--'•,- -,-,!..-.:.41-C-.--' --y 4, 4..L 1, k....__ i,. ,
(If body la to be tern arily held, . ace later) _ ------)--7,-, , 4.—"` - /77
Cemetery 7-& 114,..,. .f. Date of Burial -1.4-.-'4.t' ‘,....)...e ' 19-1 ..
(If body is to e temporarilylield,All In space later) 7
Thg Certificate of Death containing the above stated particulars, having been presented tVme. 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
Nu , and on the basis thereof I REI3X,GRANT A PERMIT-) / -----)
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the body.
to ‘,4. 4/7".4.41.4)!... m:,_ . j.4,;-4,--"-.4-... Z.(4.(../..".a,,,._. /•-22 /7./... -';'@,-/':...4 ( ,-, ' ''''' * •4__--
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the • .4_,,,e,..4-.V,(..4(7,7 .1 / ne:-.-.2.--e:..to hold temporaril 41 e) yir->lf- '''
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Dated 1 (Signed) e. -4 --7 ''...... .e.Z-. 2-`.1_,..-..
7 --- ,
.,- ,-- / Registrar
This Permit is fficient for the Removal (and Interment or Cremation) of body 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.
r
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o ;"2/ 'r l 19 7
(Intermenntt or r mn ion
3
(Name o Cemetery, Crematorium, etc.)
Section ""- Lot No. Grave No.
(signed) (,
(Person in charge)
•
s Addressi?(",
-0'3"Z'a"-- ;642422 ;;;77
4' Person in charge trust 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 words
"No person in charge," and FILE PERMIT WITHIN THREE
�3) DAYS with the Registrar of District._in a :. .,.. ,-___-,--
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.