Dougherty, Lillian Form vs.si. 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._ ""a
Village/>
Dist. No'5 6 s i County ozCity
���� (If city, ve street address)
[Name of deceased... ... ... . . .......1..1.;.,0... :. Veteran
,�I (If veteran, give name of War)
Sex dolor �F� Slagle, married, wid ed,.or divorced (write the word).... . .Date of Death '�A5% Y 19
Age.. . . . _ Months Days Birthplace
Cause of Death G� `ate - •
.. ,�e .. t--�-- 4--�y La 4,...466 c-�
Certificate was signed by �' .. . ... - M.D.
Address i 'if( '
Place of Burial (or Removal) r ... . -.! ' , - •
(If body is to be porarlly 11044 nil in space la r)
Cemetery... ------ ( A 1 -1-- Date of Burial / i/ 3/' 19
(If body is to be temporarily held,fill in space later)
This 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,
1 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 EREBY GRANT A PERMIT >
y e (Name - (Address) O
he �F--�- . .. . to hold tempo arily and the body.
(Undertaker 9r person having charge of corpse) (Inter,remove, the se dispose of(state bow])
Dated / 2--, � 19.(.),-;-- (Signed) .... ... .... . . .. Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (subject to local
mmetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSE ENT OF SEXTON OR PERS9N IN CHARGE OF
PR MI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was ' 19 -
(In to rmen t or Cremation)
Kane of Cemetery, Crematorium, e to.)
Section Lot No. Grave No.
(Signed)
(Person 1n charge)
I . /
Address r% I
Person in charge Heist return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOF or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the lords
"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 OFFINSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.