Suprenant, Ellen /Perm V&IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 RABLE BLACK INK. Town Registered No.__.._. _
' Village 07 7 1 L J
Dist. No,St L J County.. -��J er£i ...I ' ---r<- ,... ... .try )-G°..,..17. /1
(If city,give street address)
Name of deceased. 1,,e.. n.. ,#..,. ... :Cr: ,- c/.1 Veteran ,-..
._,,_":
�/ ff �'% , -. Singlej:..cliarried wid ed ' r (1 rsn. gib a of War)
Sa�w`ryw:r.+. Colo .............or divorced (write a word).. - --- Date of th '4-'-�'• a• . .19$ 0
Age 02 u Ye Months _.....Da s ;..i Birthplace / �7- t
Cause of Death .. ...... .. .. .. . ... . . . 4z "it...--t.../ .•
Certificate was signed by.. .. ,..,,..rr t......S-.- C-44— ,.., M.D.
�,- 4,,
Address. ....- ` -- .. ... -9 ;' .S...'C-- .,.. "i
Place of Burial or Removal)... :i,..:tR ,) .:j1 ` --1'ir--1.. . .
(If body Is to be porpp]y geld, in space later) � /�
Cemetery . .. ...r..(.,.f� Date of B�irial... .. —a::: ... 19 f
(If body is to be temporarily eld,All in space later)
Tha Certificate of Dea containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I e accepted the same r registration, have recorded it in my Local Record with the above stated Registered
N , and on the has thereof HEBY GRANT A PERMIT r
tN--Ly r: 4. [Namsj i,,.,..... -.G:4r,---- a�.. . .1).:' ,.. {:.{. ..ss :tc .,. /- /
thE'. ,, ,- e---L.r t„ c.: . ......z..,.................to hold temporarilyand = ,.,_- t`f a body.
(Undertaker or {/
person having cbargo of corpse) (Inter,reor otrwis dis9ore of[stataf bow
Dated ti=s....w..: • ;, 19..:a..y (Signed)z:r..- -1. ,,:... .,,: �:!:" .i,...'.....a...s.- .— -cz.....k__ .'.
r.a_,e.-•'. .' beee1-tegistrar /
this Permit is sufficient for the Removal (and Interment or Crem lion) of a`hod 4o any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,i iy which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CFIMATIONS
ARE MADE
Date o L&-:L.ry.,,e.-Y�t` was '-� 19
(Interment or Cre ition)
L.
(Name og, eke tery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) • 4'
(Person in Ca ge)
Address O . R:. ..s b L' G, • _.„, j(�
P4
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, write across the face of the Permit the wards
"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 FIVES 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.