Renner, Katherine Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BILIRIAL (OR REMOVAL) PERMIT
tr 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...... .2,/................
, -
Dist. No --6—‘6-( County.—.Z.4.:1.- - Village _.,<,./.:...6.,,frz,'
or City 2.,„ ';-.--;.- 4-6-e„...,
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Name of deceased /.....a u.:--i,...-;:.-.4-..w.,. ,L73., .,-------A-4------r---- - (If city,give strlltddrees)
Veteran
p?„ Single, married, widowed, —2,) /
Sex -‘,7. Color.. .4/ or divorced (write the word) // ----,-,Zai..c--1 Date of Death(if veteran, give
/771e of War)19 '--4-7
Age Yea 5,5 Months Days _ , ,-__y„ / /
/Birthplace ,-.."4A1--.. - ?" • - -
Cause of Death (...`-4.4-e1.7:-42---1/
Certificate was signed by ---7.7: ‘(;c..t.2 - 7 //'-- '. . ...ay. .7 .._..,-\.4 4 .44., M.D.
„.1.• •
Address
Place of Burial (or-Removal) -/- 1'1.. '-• - : : , . / =
i „.7
(If body is to be,e(nporarlly held,fill in space later) , .,,
,
Cemetery .- ' - / Date of Burial //..6 19.S:7
(If body is to be temporarily held,fill 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 SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num fk4 on the basis ther \,I HEREBY GRANT A PERMIT/ 7 ,
, -----7
to '..-.4.-...:.i.s.,' - . •d. .,,C':k....,..,,..,1 ,--•:::-.1;
—(N,z40) — (Address)
the f ' . ' to hold tempo ly and the body.
Dated
(Undertaker or perpon having charge of corpse) (Signed) (Inter,re ove, r/1...4/..,s4M—as.di ose of[state how])
...
. --- ,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematio of a body to any part of the State ("object to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
////���7
Date of ; . (�� was: //� 19 —7
(Interment or Cre�tn)
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k 2-4---' 7eCA-"---'i 6._ ( -....2.----1:
(flame of Cemetery, Crematorium, etc.)
LS_ ef---el----2-a,e--k.3
--tZ
e:9-'d
Sectio Lot No. Grave No. Z
(Sign ' --.7.,,_
' L"s./.)�.- ()) 4> (:
(Person in charge)
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Address/'�j"G � .�.<1 %k`✓"
l
Person in charge mist 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 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.