Tierney, Irene Form VS.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
AZ. This Permit llAiti 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 CERTIF CATE OF
DEATH, LEGIBLY��, WRITTEN IN DURABLE BLACK INK. Town Registered�te No.., .. -_
V
. . :.e ..County... .% Z..�k.:�.e..4�t.- oriCitge F :. �
Dist. No .. ,,....... ....,
n (If city, give street address)
. ..Name of deceased .. .. ..... Veteran
! (1f veteran, give name of War)
Sin e, married, widowed, a 19.It.d
Sead-i.
Color..io `divorced (write the word) .. . Date of . . :.. ....
Age 34' Years Months Days Birthplace .. ..z4..4.... •••
Cause of Death-... .....r �¢ •
Certificate was signe ,b1�'... .. .. .. . . M.D.
Address..... :: .a-za
Place of Burial (or Removal) Id-.7 rrit xt..c .,,,,,....„„„:,,,,,,p,
(If body is to bety��orarilylxyd,gII in ace later)
Cemetery. ����`. �,. .e..-.-t?,‘.G.YJ Date of Burial......: - 19
(If body is to be temporarily bela 11 in apace later)
The Certificate of Death containing the above stated particulars, having been presented t' me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for re 'stration, have recorded it in my Local Record with the above stated Regi red
Number on the bag' he I HEEBY GRANT A PERMIT� � �.
the �� ,tow d temporarily and a) t e body.
( n ker or person s ring charge of corpse) (Inter,rerry4 .e, thrzwiae noae,of [state how))
Dated... . ..tS 19...6y/ (Signed) LL`-&- ( /C._ .. ,......c:...F:..A..: :!- :...
Local R
This Permit .s sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (enbject to
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
Date of was_ 19 "-
(Interment or Cremation)
q I
(Name of.Cemetery, Crematorium, etc.)
•
Section Lot No. Grave No.
or 4 -4-3
(Signed) �� -14i"
(Per Ion in charge)
Address "I `.__ 4L/t / t
•
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 OH'FNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.