Duell, Stephen Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 CERTIFICAT OF
- DEATH, LEGIBLY WRITTEN IN DU LE BLACK INK Town Regist No-
- Village
_Dist. Ni.c...C. .7.County...-...... or City ii--...4e,
lb?
(If city, e reet ad ress)
Name of deceased. 07.4—../2,i, 8/4.17/70.A.5 00/€4/— Ve ran .476
(If ran eve name of War)
ingle, married, widowed, ' ci
Sex...dolor. :or divorced (write the word).. . . - Date of .. . .. ./.. ....19‘..C'
Age.. 77 Yealeezr,Mon Days 4.4‘Bit..(:45.7 jrthpla e..- ak y7,7!
Cause of Death
Certificate was signed by M.D.
•
Address
Place of Burial (or Removal)
(If body Is to be ora ly h In s a
Cemetery.. Date of Burial 6
(If body is to be temporarily held,fill space later)
The:Certificate of Death containing the above statedI)—rticulars, 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 egistered
Num on thr)basis _ I HEREBY GRANT A PERMIT
to .dgE4:7 ad -4-<„,1 ./.7 ..‘-/ -r--"--/-7,c.C>" Q -‘e.-/
(Name) Ad so
th to hold temporarily and. the dy.
(IIn.art enr,:/erson having charge,ftorpoe) ,removaar herwi nose of[state howl)
Dated / 19.0‘.--, (Signed) - 9
" Loc egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eurbject to local
cemetery or other regulations),unless removed is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
' PREMI SES ON WHICH INTENTS OR CREINATIONS
ARE MADE
Date of (.=-ham
(Interment or
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) n �� r`t� � Z
(Person in charge)
Address �fe)
Person in charge must return this Permits o
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.