Dorlan, Martha Form VS.(IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can Ira 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.__.____....._._....
.5 4G`/ Coun Village - /J
Dist. No ty.. or City / �
(If city, give street address)
Name of deceased `,� ✓,1�(e. :a(4 �' /.-267-4- Veteran —
y Single, married, widowed, Of veteran, give name of War)
Sex \t Color... or divorced (write the word) Date of Death ,2/2 A 19.E
Age 5.., Years Months Days Birthplace
Cause of Death
Certificate was signed by - 4,/ M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily held, 811 in apace later)
Cemetery Date of Burial 2....' 19.�..,1
(If body is to be temporarily held,fill in apace 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, acid on the basis thereof.f` HEREBY GRANT A PERMIT
to
K the 1 -- •tr--a•(.- 1'-{-----1/-'s Y--
( i�� --(Address) •
to hold temporarily and . �c r--k the body.
(Undertaker r pe having charge of corpse) /' (Inter,remove,or otherwise dispose of[state how])
Dated ? 195 fr . (Signed) P e, ................
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.
E.�� —Z-J 2 C,-le
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date d a
o -- -,:-r� - �7 � --� 19 �, 7
(Interment or Cream tic�
i� ;�2�
Z_"," ,Z--ffs) (Name f Cemry, Crematorium, etc.)2
771V3E___G:37A,a;:t_a__--•
Section Lot No.:5 0 P Grave No.- A-
(Signed). �E' ,,'r -�--- �-E�/12-C.�kea
(Person in charg
Address /J/)� 2.,, 2.e— --"q&----- --t94 ,----
4-
Person in charge must return this P rmit to j
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.