Philo, Irene Form F&!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (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. Z7
'/`� Village �` ��Dist. No SbQ Coun �2et h",CY . or City...............
(If city, give street address)
Q
Name of deceased XI.... . ...� Veteran — —
�j�� Single, married, widowed, (If veteran, give name of War)
Sex.. � Color....,f'� or divorced (wnte the word).2?2-? !/ Date of Death * 19...7/
�
Age .Yea s Mon s �/4 ,,,,,,,, . Birthplace..../� c.r/ /I!C....�'Zia-
Cause of Death �... .. . . .. ,,.,l... ''f -4-0-
Certificate was signed by c ., .. ,,..� M.D.
Address � < �-� `7�
Place of Burial emoval) „ /.I�J?2 1 ... �.�G z� �-1 yi
-
(If body 1s to be to po a y held, ll in apace later)
Cemetery ( ,.L �e �/ U .!'..?mot.. Date of Burial S77 19..57
(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
Number on the basis t °f I HERE$ GRANT,A PERMIT
to .,.4 thereof
.... . , .c.. ..��.9QrrrL.a, 17lc,. ,. Lz.,.
-- (Address)
the to hold tempor 'ly and.... '.. .. .. . the body.
(Undertaker or person ring charge of corpse) _ (Inter,rem , dimose of[state bow])
Dated ...7 19...<.4 '` (Signed). . l
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematio of a body to any pert 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.
ck , � •
.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
r
Date of _ Lc, 19 /P 37
(Interment or re ti
ame of Cemetery, Crematorium, e
Section 1-3 Lot Not '7 C Grave No.
(Signed)
Person in charge)
Address
Person in charge must 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.