Mulcahy, Timothy >fiwa vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__4 S 7
�/ Village 7_ ,jj
Dist. Iv'o....2).. -.../...Cotmty...� �e -...G'da?: .ld or City f. :`�.✓
(If e.t1', glue street address)
�/r`/
t
Name of deceased �7_t...... . ... Veteran
. ......... ... ..... .
(.Single, m ,,. idowed, (If veteran the name of War)
Sex Color..tr. or divorce (wnte the word)` !9L. -- Date of De / .: 9�.
Age 3—.C7...Yea Mont]11, ... .Days Bi lace..., .: � ••� ' ✓
Cause of Death Lhs. . •• -4•• �
Certificate was signed by .. = .G.u�. M.D.
, ..
Address ...
Place of Burial (9 Removal .. .... e„�? ; '
(If bodyis to be tem ril ' .. space later) l/ 19
Cemetery ..,.V.- G./ �_,,•• = "Z� c•✓ v . Date of Burial 7
(If body is to be temporarily bel; 11 in space later)
The Certificate of Death containing the above stated particulars, having been present'd 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 Record with-thee above stated Registered
Number, ar 'on a basis the HEREBY�GRAN�`)A PERM IT -✓�_g '
]/
• ( ���� "1.421 (Address) /7
the to hold temporaril and.. the body.
(Underta a.r --raon ring c arge of corpse) (Inter,remove,or�erwise dispose of [state bow])
Dated ' -ve�'''[ vZ'19..‘.'-- (Signed) .. . . .. ... ......
Local Registrar
This Permit if sufficient for the Removal (and Interment or Cremation) of a body 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 SEX'LUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE
Date of was c2 S! 19 6 Z.
(Interment or Creme )
NJ/.
(Na of Cemetery, Crematorium, etc.)
Section vV Lot No. C Grave No.
(Signed) • O '
e--R4C/C.
( neon in charge)
dress 3 s s ? -
F1 cdf2,4,_H N
12-See-1(4-
Person in charge t return this Permit to '.-
the Registrar of his District within; SEVEN (7) DAYS
from above date. If no person is ink 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 ONFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.