Chadwick, Lulu Form TB.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t! This Permit earl 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. :a. _.....__
t �./' Village ��� %��
Dist. No County.,... lxz.. or City
/� eZ�GH� ,q (If city.give street address)
Name of deceased .. � f/„�r :��;y//�L� Veteran —1.'y,�
J/ Single, married, widowed, ��j (If terse. give name of Wu)
Sex Color i� or divorced (wnte the word)...XT Date of eath.... ... ....... 3 19`
AgeCau of DeathYe s Months s Birthplace ,...�
--
Age '7
rx :Y..� .... .. . �nz
Certificate was signed by t` M.D.
Address ��L �`—� �� 7
Place of Burial (or Removal)
(If body is to be s i or y hel 1 in space later)
Cemetery .f�'.7 / • T---' ee1/71• Date of Burial ' 7 19.'/
(If body is to be temporarily held,fill in apace 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 cepted the same for registration, have recorded it in my Local Record with the above stated Registered
Nu iiira . • on the b thereof IEREBY GRANT A PERMIT
to .42 � Lv G `r �t 4'.�i
j� (Na (Address)
the � cFz e1 to hold tempor ' y d..,, .... the body.
(Undertaker or person h .ing charge of corpse) s(Inter,re e, -alli a of(state how))
Dated ‘ .--�?` 19...‘,4 (Signed)
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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PRF11ISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date•of / was v 19 �r+ (
/ (Interment or
/ ,
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
• �
(Signed)
(Person in charge)
Address
Person in charge` t return this Permitthe 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 OP TENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.