Rivers, Mary Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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 INK -Town— Registered No—cll.-0 ..
Dist. Now °/ CountyV:City ; // /�/�
...........�`.»tier-- or City ,",,.�:t�i�a�:x� ra 4%e� - i(If cit street address)
Name of deceased Veteran
't.)�e, , arried, widowed, (If veteran. give name of War)
Sex...f o 1 o r or div. ed (write the word) .Date of Death #"2""'We ...... ..19..�..?
Age 0 7 Yeas Mo ths. .............Days Birthplace ' .'
Cause of Death , f
Certificate was signed by. M.D.
Address l o.. .. :..
Place of Burial (o Rem / mo oval) - t es V
(If body Isto be ora y d,fillSpace later) 1 _Cemetery Dat of B — . ....� 19 5 /
(If body is to be temporarily h d,1111 in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFAC!'ORY 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 IZs thereof I HEREBY GRANT A PERMIT Q ��
the �+J�� ( ddreas) =:
(Undertaker orto hold tempprri and the body.
person having charge of corpse) ,' (In r, o rwise dispose of[stay.bo
Dated....— r: 19..`..i...f' (Signed). - .4.;,. -. _ l-.---C x-.:: I Ige()—:—
1 Local Registrar y
This Permit is sufficient for the Removal (and Interment or Cremation) of a 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.
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Adss in this Permit to
K {?sot ) DAY5
return
Person in charge is Distri sa i :411 tosS,.0perSrazof if no YerRlitothe v'°rds
the above date.it or 'UNOT�f "peomPeirmirtITl1INTt�from E01' DIRE aT� ssty e fedgIt in whicl1
1T� write in chare' tray of Dis
„ per S the Regis
{3) DOS with.
located•
cemetery and VOERTA�its
F�E�,I, DI���to�e rein FIVE D4L�'AE1R
S�TONS> relative IESS T� OS�•
the law ty 0 NOT To, FI T axe re-
quired, to a Pen volt
Registrars .mere°f•
are liablet4 T FIPT forced• Weal report violations
NOR w will be penalty, to x po
��1lede under Yam'