Paelte, Jennie Form VS.et. 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 FLUNG and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INKn � Registered No.......ti. .
Dist No,� d/ County c".--, �_ or City ��'ie /` "
(If elty, al e street address)
Name of de eased ` -��� �� ... Veteran
l /,lSingle, marrieQ, wid ed, (If veteran, give name of ar)
g t
Sex ., 1 v� or divorced (wnte the word) ate of De " •/ ;1�j '
Age ..•.Ye .Months Days Birthplace - `-���
Cause of Death-Death.-.. — - �.• , . .... •C :�a'{
Certificate was signed b ••� •.f• • - -' M. if
Address .•, °"-'
Place of Burial (or Removal) lY! . • -
(If body is to be tempo bald,fill in spamlater)
Cemetery L-( !/�(--e .) - C-4--( •Date of Bu _al / — c2 .7 19 6
(If body is to be temporarily held,fill in space later)
MA 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 Reco with the above sated Registered
Nun/ir, the basis t I HEREBY GRANT A PERMIT _C/
ame) Address)
the / ire. .••• ••• • , ' to hold temporarily and -rc-' e body.
(Undertaker or pereoadiring charge of corpse) (Inter,rem ye,or otbe se el,limole of(state howl)
Dated.....•- r.:.•..6 19... .& (Signed) ''- .
al Registrar i
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to y part of the (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Tran • ermit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
2., .2 f
Date fj was 19
(Interment or -. )
,��L
(Name of C metery, Crematorium, etc.)
Section Lot No. Grave No.
/
(Signed)
(Person in charge)
Address X� - �.�
7
Person in charge must return this Permit %° -.
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.