Phelps, Lilliane Form vs.SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 I . Town Registered No—
lanag
e _
Dist. No..1.....S...tounty.....Lc,..1 - .... _ _ t...-
(If city, give street address)
Name of deceased i
0-‘-L-' \).N.,,,L‘---f .,1.\,. Veteran
— Single, married, widowed, , N (If veteran, give name of War)
Sex.ttild.‘....Color it.' or divorced (wnte the word) '''''-`-{3"1:'r.4-'-'44-k Date of Death VA-al k 9,, 19 )-(1
,-- ,
Age....1( f- Years ,.Moths ...--..Days Birthplace lie.,.14-...4-0.k.
Cause of Death Ilia,k,%-k.„ .,,` L t-4.....s.... _ .......4„ ... (,,,,,,
rI' , .. '41- 5) ..!,
Certificate was signed by t- ilk •.•.Q-......-:-.L.1..'"-L-- L M.D.
Address thk.r.-.. ......... ---......,-$.-..-. S."K\A-L'''''' \N• ' L.'\
Place of Burial (or Removal) <i ,--`"-"--, L. I'--
(If body is to be temporarily held,ell in space later), , A,
Cemetery --t, • ....-.A.-
) 4.- -4,il - c'• -,' Date of Burial N•.tv. .-1\ 1 5 - 19 ...1.-1
(If body is to be temporarily held,fill In space later) ,.
Thu Certificate of Death containing the abo'be stated particulars, having been presented tome, 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, and on therbasist,thereof I HEREBY GRANT A PERMIT
to
, \ (Nuns) k (Address)
the ' L.,.,....t. .i...)L -ek. to hold temporarily and -" i. L....,,h,:.k.. the body.
i(Undertaker or person having charge of corpse) (Inter,remove,or otherxise disoose of(state bowl)
Dated..‘..AA-.C.". i 19 ..'3... i (Signed) \)4.1„.1.. .., -51,_,L,L,A,_ 4:-.1 1 1-K-s.-.t-- "--'-'
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to ocal
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
b
ENDORS IE T OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
r
Date o J Z-[� 19 7
7
(Interment or reuati
,,,ez:Z...,
Ze.. Or 2 - ,
(namee Cemetery, Crematorium, etc.) _,
Section Lot No. Grave No.
(signed) L a �.., , C "C�''11 ,
( non in charge)
Address Ae'`,,`
Person in-charge nest return this Permit to C_/ '
the Registrar of his District within SEVEN' (7) DAYS
fran 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 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.