Mabb, Shirley Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
is This Permit can ha 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}LATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__..40
r // t� r I i ge
Dist. No3..2.G2 d County.L.�.1.a SI 2 o-isy �t�'C,43YL1 W e-bkL.) eb
f - (If city, give street address)
Name of deceased.. )11..4.46—"
..? ��` il: 0...e Veteran _
ll ' �n _L Single, married, widowed, vetean,' sips name of Wu)
Sex.�1 . ...or divorced (wnte the word). .. Date of Death hi 19.42.
Age .. c ars if N onths 1I
yrthplac�Cause of Death ►.... ... . .. .0/4 .... ...�.1.�... .14.c4 aAGia
Certificate was si d by.... .,4. NE4, a.Q.rt� &&'L,i
Address h 9 - �� /�
Place of Burial (or Removal).. /.,4 .t. .. Ch.�irt/L1./It:L t`1.2r �II�LRrn/ �=4• ?I.- �.1
(If body Is to httem�porarf h 1 In space I .r) n n
Cemetery...1cL/geae/.....K!Q•l�.Anal.......... . Date of Burial . . 9 19.424
(If body I.to be temporarily 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 Record with the above stated Registered
Nuj , on the aria the I HE EBY GRANT A PER Iu.etzmv 404 /
Na . 1,4t (Address)
to hold temporarily and.... the body.
(U dertak or➢e aTaving charge//of corpse) �IntP�, re ve. iker�jlse dienose of[state how])
Dated C 'L 19..4A Z (Signed) .GCnI-�..Gr .... i
Aegir Regisr
((JJ trar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body 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 CREMATIONS
ARE MADE
4 .1.te..4_./...,w (v, r,,
Date of z 7' was , 71- 19 2..--
(Interment o -
is
7e;
r
(N&lie of Cemetery, ematorium, etc.)
Section Lot No. Grave No.
(Signed) G4(k. cr -�.- 4 c-z ?Z-Y
(Person in charge)
Address / �_ /, ` y ,1—,k :;--*"-
_r.__,_ Xe-- T4 ,y 2,-
Perso(in charge must 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.