Monf, Mabelle "vray VS.gL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ga 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 CERTIFIC�T. OF J
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No—
Village
.�-
Village
Dist. No. (v 0.1.County..... . :�--» "- or City r&&-- Yc--Lc. 4 -/� ..
(Ift city, give street address)
Name of deceased ( -t `- /' Veteran
Single, married, widowed, (►( veteran. give �'of war)
Sex ,.color --' or divorced (write the word)...... -" Date of Death 19.&.. .-
Age / Year Months , ......Days ,/�/{J L B'—yplace //j^Yi/Jp /L //f��[
Cause of Death
Certificate was signed by.. � ge ....... M.D.
Address 3 - • Y•
Place of Burial (or Removal) -- . :-.--.: ' :¢-1^-s -'"A--7.... ,f R•7
(If body is to be temporary held,fill in space I ter) ,,, r�
Cemetery - 'Z ' ;.::TR,..�;.�::-- - Date`of Burial -" ....,/� 19
(If body is to be temporarily held,till In space later)
The Certificate of Death containing the above stated particulars, having been presented to e, 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 Record with the above stateded Registered
Number, an n- the basis thereof I HEREBYGRANT A PERMIT
•' -/1r. ` G
to., . �� i�L.4..i.x.. ... r..,6.rr... (Address
,,)) Na ..��
mil/ .. - .i_ -�1_. the b
the ,.�;4,,,�, �-- to hold temporarily and., .� Y.
(Undertaker or person having charge of corpse) ,�t (Inter,remove,or otherwise dlsooae of[state bow])
Dated '5 `I 19.�!ir:-- (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 regulation), 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 719
(Interment or
4-4
rf (N me of Ce etery, Crematorium, etc.)
Section ' Lot No. Grave No.
(Signed
(Person in charge)
Address(/� /(\J/`�/
fAr
Person in charge oust re 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.