Sone, Myrill 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.._...._........._..........
Village Guilderland N .Y
Dist. No....15.5....County Alb y or City
(If city, give street address)
Name of deceased Myrill Sone Veteran NO
Single, married, widowed, (If veteran, give name of War)
sexFemale Color W or divorced (write the word)...WidO.Wed, Date of Death ..30th July 19 ?
Age 8.2 Years Months Days Birthplace Canada
Cause of Death C.abe.=— vasculor...aematQ.x:xhP-Ze Generalized arteriosclerosis
Certificate was signed by Ler.}aer.t...W......Gra er M.D.
Address Altamont N .T
Place of Burial (or Removal) 0.3..C'.X1S Falls N ,Y
(If body is to be temporarily held,fill i .Dace later)
62
Cemetery l.nevieW -emty Date of Burial Aug. 1st 19
(If body is 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
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to FQ.rQr ES Bidleman Altamont N .Y
Name) (Address)
the Und.e.rt,ake.r to hold temporari alJd ^ inter the body.
(Uni1e{takpr o person acing cbarggrot corpse) / 1( me e e, r se di ose of [state howl)
Dated "1st t 19 L (Signed)
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Slate (subject 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
•
Date-s._--,£ , 19 1
�wzs if
(Intement o�Ceemati ~
�� 2/7:-- (17-1" ((Name of Cemetery, Crematorium, etd.) .
.
Section mol Lot No. Grave No.
(Signed) �`s (Personin --4 charge) 2C �C
r / / ,
Aadress�: ��LL �-�.•�,
I, J
Person 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.