Beagle, Freda NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
«' This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. J�
Town, V a Re tered No. �
Dist. No.. r/�� ount}�i �� :(...4cit. or Ci ���.r' li �ti .
A '%% t dd
-,n (If city''JJ��ve str eta ress)
Name of ceased . � "..,- Veteran lrl u
. (If veteran, give name of War)
I
Single, married, widowed, i
Sexes. ;_al-Cam/ or divorced (write the word `e41 Date of Death '--.1 19 ..,�..1
Age... Year Months j Da . Birthplac'� ' V
Cau of Death !!,. �,�', �-'
Certificate was signed by ...,f "t,i-:._1 M.D.
Address / ,rl� �J:r roc _ '...4d 1..-G�e cn- y� z,
Place of Bprial (or Remo Gti ' /
(If body is o be„tern rarely he y(ill in lacer ')
Cemetery...........rr,..0 �. -G� ' Date of Burial ., 19 /.
(If body is toe'temporarily held, fill in space later) �`
The CE'TIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same ring to be COMPLETE, CORRE T, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, h. re. orded it in my Local Recur .ith the bove stated Re s ered Number nd on the basis thereof I HEREBY GRANT A
PERMI /
to mow/ Z.: .........„t -44c'f yL,' 'I:ti2/ QX:,' '
(Na e) .�..�Aad s'
the .... .. ... to hold temporarily an- ' .., :i.1 the body
( n erta er or p5son ha.ying charge of c p e) ?4.' rem r herwise dispose of (state how))
Dated 19..' . ....... (Signed) i _^
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to /ny 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.
F'OItM VS. 61. (ItKV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
7/_"
Date of Y' j,��[e� was 19
(Interment or Cremation
J721
(Name of Cemetery,Cre
Section Lot No. Grave No.
ki (212/
(Signe
(Person in Charge)
i
Address / `l _ / G�/�' � ✓'
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. lino
person is in charge, the FUNERAL DIRECTOR or UN'Dt-
TAKER MUST SIGN ABOVE STATEMENT, 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 required, under
penalty, to report violations thereof.