Hermance, Mable -R>x vs.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Clr 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 CERTIF ATEQ OF
DEATH, LEGIBLY WR IN DURABLE BLACK INK. Town istered No._..._._... f
[^ Village ,i
Dist. Nog.:7County . sue"`— o
(If city, give street s)
, I..
Name of eased A .4? )4cqiMp# C e. Veteran '
Single, married, widowed, (If veteran, give name of War)
Se�q .Colo . .... .or divorced (write the word .."
. . Date of Death.... '. CS..." 16. '
Age Y ass Mon s ... »..says • B v • j C ,,.A‘41 • ��cy�
Cause of Death
rr
Certificate was signed by..... .... 4 r .. M.D.
Address 3. � � .. ."',AIr0 —... .. ...
Place of Burial (or Removal)
(If body 1s to be te�porarlly held 11 to space later) - - `
Cemetery ./► 1 m Date of Burial ice/•-� 19
(If body is to be temporari 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 th ba a (thereof I HEREBY GRANT A PERMIT
to so), m °' ��c
the "• .sins) P y 4 l 7TAddrese) the body.
((( to hold temporarily and
(U er ker g=person having charge of corpse) (Inter, remove,qe otherwise dispose of[state bow])
Dated ((�y�P�' {/��p 19- (Signed) t!. .,..A.*e
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the date (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 CITATIONS
ARE MADE
Date was 7 19
Into t or Cr
i
(Na of Cemetery, Crematorium, etc.)
Section Lot No.,•►, 7' Grave No.
(Signed)
(person in charge)
Address
Person ' ge must turn this ermit 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 OFFb.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.