Viele, Bertha -,--t,yfi.ei, NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Cr 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.__.
Village
Dist. No).,5.. .County...S�L�:.G$.1i hat rl�...... or City . . .. ...
, (If city, give Street rss)
Name of deceased..l �,,-(.C+•.l..L�. Veteran
ff,,��Single, married, widowed, (If veteran, give name of war)
Se.•Lei .Colors. .ek.:.or divorced (write the word) Date of,peach. ,.•/..t....f . 1�
Age....,�- I Yeas onth Days Birthplace.,`.i�g-.' .. ..2:,)• / •
Cause of Death .. /
Certificate was sign)d/by.... at..4..a.. - :..�. - - _ M.D.
Address .:` :
Place of Burial (or Removal) lit-- •== -6-�c.�•`•'. . .
(If body is to mDorarily geld,fill in 3pAce later)
Cemetery. .Z/rl.44G4::::-U...t..i:r s.ky Date of Burial.. . ..,../... 19.‘.. ----
(If body is to be temporarily held,ell 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
Number and on the ba ' thereof I HEREBY GRANT A PERMIT
to 1P. ' .x,�.c,z..3l..�J ��� ;:�!�1..Jd:! �—. ,c� o �C1 �� e�,e�a �1. ,.�' �•
71"'":.t
.. Na dress) :
the to hold temporarily and :¢:,.' the body.
( dertaker or person having charge of corpse) l (Inter, o , otherwise di+e*�ose of[state jowl)
Dated. • / ? 19..6.lr (Signed).../ "' . : g�tu.<..-f� a[.k. .... . t�Nd
Local Registrar '
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.
INDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INT. RMENTS OR CREMATIONS
ARE MADE
�� �
Date of- 'i)•.-/s was ; ., e c_ , `c' 191 2--
(Interment of Cremation)
/s...e.,/ j ' / 'Z.---
J am` (game of Cemetery, , rematorium, etc.)
L 27 t+I�re.S-7-S----.,
Section_.,- - Lot, Fri Grave No. r,
r / .
(Sighed) "l>i.'/>Cd =:;._. C- "1/r' (C
(Person in charge)
Address �' F
L(7)16L/ Z- _ _.
Person in charge oust 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.