Worden, Gertrude -ur m vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Perna 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 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town egistered No.__.
Village
Dist. No..:�.Vl Cosuity... 4r� or City
--. \ (If city, glee street a re )
Name of deceased.... .. �.tL. Veteran
��}} ( �—..SSingle, married, widowed, (ArdcAsr-2.4.
(if re give name of war)
Sex :'^ri°`(Colort,)� ' 't.,or divorced (write the word) ff �
..1✓]1.. :::....Date eath....�^� . ....1
Age t� ....Y the ........Days Birthplace`"'' Q .
Cause of Death...... .. :. "
Certificate was signed� �r`-1 .. M.D.
Address ... .. .. . ... ..
O
par$Removal) r � s.R. ,;,,, Ct* �
Place of Burial or
{If body la to be tem y
ily held, fill in op ce later)
Cemetery Date of Burial 19. ..�--
(If body is to be temporarily held,fill In apace 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 Regis ered
u andet jthe basis there� HEREBY GRANT A PERMIT _� � ee..
to s � :te ,.,___ ,- ....• 19c C A ""` Lam91.,24tv.
(� , (Na .... .. , (Address)
the �-/ �� to hold tem orari and the body.
(Undertaker or person having chargeof corpse) p (Inter,remove, th ,.le dlsnose of I. w]) y
Dated — _ 19 (Signed) ... 2::... ... ' L. .�i,.�l.: --
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a lately to any part of the State (subject to local
cemetery or other regulations), unless removal is by common currier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMITS OR CREMATIONS
ARE MADE
A7-/24-
Dateoft)i t ' �_�3 19
/ (Interment or t ��t�l�E
(I(ase of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
-74:
(Person in charge)
Address � � Gin
Person in charge must return this Permit to
the Registrar of his District within SEVEN CO 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 OFKL.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.