Hulbert, Ira Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Perusit eau Is• 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 Registere9 , o-
Dist. No (9°./.County _t(--)C)-4-7(e--11 ._ Village
or City A-12-e--ut-ig -a---4,... , 9 -00(
Name of deceased 1-11""- ii . ,,gi,- -, --i (If city, give street addre
Veteran 0
(If veteran, give name of War)
,
Sex. riNAP-PlColor IA-14 ingle r divorced (wnte th married, widowed,e word) -6" Date of Death / 19
Age -5-' 7 Years Months Days Birthplace... t. . ....... ... . . .... . ../..
Cause of Death C.- i/s0
Certificate was signed b --r• ., . M.D.
Address
Place of Burial (or Removal)
(If body is to rorarily held,fill in space late C)---6... •3. .e.,,., a
Cemetery.. .. ....d...41s-4..... ...14r9refeU Date of Burial i 1 —
(If body is to b temporarily heli,till in space later) 19
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
Num antn. basiseereof I HEREBY GRANT A PERMIT j/00 . _,A _I, fryalev 47
v----:-----
the luAA--"f2 )
to hold temporarily and .....ik.xeci,___(Address()
the body.
(Undertaker or person having charge of corpse) (Inter,remove, r other.?disnose of[state how])
Dated .4,-.Y....--4-1:1A G)...' .C.1 194 9---- (Signed) 3 Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past 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.
ENDORSEMENT OF SN'X'IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of �,L 64 w._ 7 �c. ',�/ 19 Z 2—
(Interment or, attaw}
. / ALE--- �--.__ 4''%Itc.�L 2
i f
(Name of Cemetery, Crematorium, etc.)
�� :/
Lot Section 7,�// - Grave No.
:-/5 '
I.
(Signed) !-..,r1&H -C' 7 _-C7`- :=7'r-.-.,-- `E.
(Person in charge)
ii-
0.-
Address LCN,74 r% 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.