Leer, Mabel -r,rm Vs.SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Lae' 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 CERTIF AT OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered N _._...._ "
/y
winds
Dist. No.5 �!. ..County......
(If city, give s t address)
Name of dece sed...//. :Q�� .,2 Veteran
Single, married, widowed, (if veteran, give name of War)
S Color s divorced (wnte the word) Date of Death.�r%'"! .g
1 .
Age. ..c hears Months .... ys Bi;tllplace /
Cause of Death C..• g•�^�
Certificate was si e by.. .. .:.1`1f ` .! M.D.
Address.. . .. . . r
Place of Burial (or Removal)
(If body is to be temporarily hel fill in space la r
Cemetery..4A:.: . . . . Date of Burial... �.1. 19..a.`Zr
(if body is to be tempora ly held,fill in space later)
The Certificate of Death containing the above sta ed particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hay ;accepted the same for registration, have recorded it in my Lo Record with the
above stated Registered
Nu , on the b is hereof I HE Y GRANT A PERMIT ��-� '
7.
to .. ....to hold temporarily and._... (Address)) Y
.. . ...
... .. . . . the body.
(II de Yer or person having chargyyof corpse) (Inter,retin re r herwise dispose of[ how])
Dated....X 1.5 19.la2 (Signed).,�l�.,c . 4
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) o to any part of the State (.abject 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE
Date of 'Zf2q / was 19, /? 2
r..din to rm nt or Crema tieRr�.
fte
(Name of C netery, Creme to rim'', et.'.)
Section 1 Lot No. 9 i 3 4imiwe No.
(Signed)
(Person in charge)
I'"1
Address V114,11..t
es J{� ,� �+C.�
V � "^Y7
LI"'44/714
F#1
Person in charge mist 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 UN)ERTAKERS
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 OPTIA SE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.