Smith, Anna Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
/r This Permit cast 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 CERTIFIC4 TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK "- i Registered No._._.__.. ..�.....__
/ Village C ._
Dist. Nei(0G� County.....& or City _____.6......„4,..Q
S (If city,,g2 street address)
Name of de ased ''.7,-A-:?..,-;-.2a.,,et.....-:../ . .. Veteran
Single, married, widowed, J (If veteran, give name of War)
CauSexse
.. C r �'f.� or divorced (wnte the word) "� Date o . eath /l
Age �/ ....Year Months B. place. ;
Cause of Death P .. ... e���z
Certificate was signe y M.D.
Address / --3
Place of Burial ( moval) - Z
(If body is to be tempor y held,fill 1n a ater)
Cemete .�(...� ���-u) - Date of Burial . ` 19..W
(If body L to be t orarity 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 SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local eco with the above stated Regi steered
Numb and on the bag' thereof Y GRANT A PERMIT / 7, ��'/.
( ) drt I
ss
th' -n.�.. J to hold temporarily an y.
(Oada ker or perso having charge corpse) - (Inter,re/ e,or pthe dispose of[state bow])
• .� p g�ootr ! �
Dated / 19. P...( (Signed) - 4.,
..,.... ..:...: - ;=rim--t*�"''.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Slate (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'UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CRBIATIONS
ARE MADE
Date of 4,-L( ,. a-z - 2- 19 f /
(Interment or CrCr mation)
_/,:i _ e,---2 1_
(Name of Cemetery, Crematorium, ete.)
Section �<5 ' - ' Lot No. ,�(/7 Grave No. �'
(Signed) 7 c��--."- '-�- '\-��`�`7 /
(Person in charge)
Address ‘�/--C �� •-- -----(b,
( _.,2,-9 - _
____ ‘. __c.e_____, x.-2--g_2„,
Person in charge must return this Permit to 'J
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOF 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.