Adams, Madaline Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr 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 41ewri Registered No._._.._...._........_
Village
Dist. No..15.4........County..._..kj.. §X or City Ta,ggzld.axbg4
(If city, give street address)
Name of deceased....klaciAlirm...AslazaA Veteran 'la
(If veteran, give name of Wu)
Single, married, widowed,
sex Female Coloralite or divorced (write the word) Single Date of Death May...13., 1959...
Age 68 Years Months Days Birthplace New Y4r}f...atat.e
Cause of Death..H.Y.PP5trai14...j2z1 Ida.0.1i,a;...Cr3.che.xia;..Cserlexr lz.fed...znetastase.s..rzf:..1ym—niyo.sarcortla
Certificate was signed by...B.UdA.1.p.la..,L...k ax:tixt M.D.
Address licoxidAxnga.,...N,~w..xoxk
Place of Burial (or Removal) Q.ueansbuzy.,...Liew..Ynxk
(If body Is to be temporarily held,fill in space later)
Cemetery Pineview cemeteu Date of Burial May...144.. 19..59.
(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 SATISFAC!'ORY 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 basis thereof I HEREBY GRANT A PERMIT
to Kirby...p....dilcoz .Ticrand.er ga :—.New—Yank
(Name) (Address)
the.....V.d.1CG.44.o.r to hold temp rarily and Inter the body.
(Undertaker or person having charge of corpse) ter, nvr, th ae di nose f[state how])
Dated..Aiay...:.2, 19.59.... (Signed) C �`
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past 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.
ENDORSEMENT OF SEX'IVN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE )j,
Date o
(Interment or Cremetio��/
2J
(Name o! Ce®etery, Crematorium, etc.)
Section d� 7 Lot No.,3 73 Grave No.
(Signed)
(Person in charge)
�i Lr
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 OHF1NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.