Thornton, Elizabeth Form vS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
n 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 F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. T cwn____ Registered No.- �z._''....0
Village Dist. NO °/ County... `-�-- or City
F ,, -
--./ (If c!CS•, give street addres
. -r%
Name of d ceased -< &-.7 „f , ,,,„e Veteran
Single, marri widowed, (If veteran, give name of War)
Sex _L color....�� or divorced (wnte the word � .Date of Death /e) -- Q' 19.�.f
Age .? "7 Years. Mo the _ .Days Birthplace
Cause of Death
Certificate was signed by r --er.,741- �L M.D..D
Address. . .. ..
Place of Burial or Removal) "
(If body is to rarily held,fill ,cevlater)
Cemetery... -----(---r-%.-41 Date of urial ��l 196/
(If body Ii to be temporarily held,flit in space later)
Thg 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 co with the a ve stated Registered
Num. and on th b is ERE GRANT A PERMIT G�a,
to...w Y, . -
- ,
(AdQ as
) /
i''�
the l-� u to hold tempo d... ody.
(Ul19j rtake or person,having charge corpse) %J (Inter,rem. ' t se.a hate how])
Dated.../i/. . / 19.h( (Signed)��``' "/ '. / OF — /
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a body to any past of the State (r.bject to local
cemetery or other regulations),unless removal is by common carrier, in whic,ese a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
z,
J1
Date of - / �'was ! r -19 ''•
(Interment or Cremation)
i„,,,pC
z,-7 : ,,,--7(--- -
O ‘te.---
(Name oT Cemetery, Crematorium, etc.)
-1'1 -e-e---- (1--;-,--- -/
Section Lot No.' Grave No. --
(Signed) ...41_,gl
(Person in charge)
Addres l •
Person in charge Heist 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.