Branch, Gifford - /I (.,,) t At. Le. ri,+l 1 •,./
Farm V8-.SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Pernik 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 DURAW..E RI,JC.X.Ili‘,„ - Town 0 . ' Registered No
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• 146)V I „,-, i 1 t.„.);- :i.,--. Villagi? ,? • . . , . : - ,,, ..., ,--: ,.,
.r City I
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p
r _ (If city,give r .d a)
Name of d sed • A Q ' IF i re
"6.41 gle, married, widow . /
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. .. .001&.. 0./.Dat-
Age 7/ Years. ,---- ., Qnths ,
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Cause of Death ie ' ' i/
Certificate was signed by law; Air ' 'I. M.D.
Address. — .... - .., .. -- ......S .
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Place of Burial (or,Rem Iva ) in 7 -4:0 , /24 :7..4. ,
e body la to b mpo y space later ./
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Cemetery e .r. Date of Burial ,, g I 9r•f.—7
(If body is to be temporarily held,All In space later) 7
The Certificate of Death containing the above stated particulars, having been presented to me, a ter careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepd the same for registration, have recorded it in my ;,cal Reco ,, w. . the abo s ed Registered
Nu "', °le' basis .ereof I HEREBY GRANT A PE' %. f_ . /
4(Apfressa e,tm.ol de , V.(..1
t 0 ‘••(..h. el1051.1ne if/ .40 ./.• •
410. ., "re
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the 0 .0''. to o p a a th .•. .
(... .. :,- . . .n ha,"charge of corpse) (I7,- ..• e .r othepyise dispose o state howl)
Dated . ....' / .19J7 (Sign
This'Permit is en .cient for the Removal (and Interment or Cremation) of a body to any part of ; j— ( • t
cemetery or other regulations),unless removal is by common carrier,in which we a Transit Permit ( :0 , ,„,",.. qu
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ENDORSEMENT OF SEXTON OR N IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
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' , .ae, 719 J
Date of -, , -I • Was „, ,7
i(Interment or Creme Lion)
'''6144-e 41----" (4
Mame o Cemetery, Creme to r
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Section Lot No. Grave No.
(Person in Ow
Address ,
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Person in. . iniv.t .r.e this Permit toL,_/ /
the Registrar of his Dist7,%ct within SEVEN (7) DAYS
frco above date. If no , erson is in charge, the
AI, DIRECTOR or UND7iTAKER MUST SIGN ABOVE STATE-
write across the ;26ce of the Permit the words
"No person in Charge," and FILF 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 bc c: forced. Local Registrars are re-
quired, under per lty, to report violations thereof.