Hopskins, Ruel Form V&!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar nil P•rtnit eau Ira signed only by the Local Registrar (Deputy or subregi4trar) 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—..4...4--....L.4....--
Dist. Nol...f.6.gii.County (-) 0-31!:7A-. emeN- Village ,.._. 4A_.„,s, 0,,,q.__,(,:eiv_ A,
or City
zrig,afte..i:„.ii, (If city, give street address 7)(_.: Y
Name of deceased.. ..i—f-t9.4" .7. Veteran
(If veteran. give name of War)
a) Single, marri widowed,
Sex 4.1 ..... plor C'''-7—<:4,
or divorced ( nte the word) 'le Date of Death... ' —
Age ,1.. _I'fr$‘2...7„.........4.i.ytip.....................Da.ys \ cc
Cause of Death j .
•
Certificate was signed by ' M.D.
Address J. 7 vael---t-:-.--,.--t-,..
Place of Burial (or Removal) ' ,!•:.-..21.•
(If body la to be teiipomrily held,/1111 pa later)
,.—
Cemetery " 1.44----`,-12-56--74-- Date o urial 0 ' •: --. '. 19. ...7
(If body is to be temporarily held, fill in space later) -,
Thu 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 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 the batis th f I HEREBY GRANT A PERMIT..
,--
/0____4/.4e./
to.......t. 1 -
...v c .
to hold tem 'ly d 4 body.
(Thutertaker or person having charge of corpee) . (Inter, mov 412.70,fai nose of(state how])
•i.
Dated. (Signe
Local Registrar
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.
ENDORSEAENT OF SEXTON OR PERJN IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date
(Interment or Cr motion)
Z.;;;. /r/itlya3
41/.,41-
(Name of Cemetery, Crematorium, etc.)
Section Lot'No. Grave No.
(Signed)
(Peraon.an,charge)
Address c: , : y�-
•
Person in charge st return this Permitt0(
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 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.