Chitty, Helen 'or, VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir 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._s2.._.Z.Z
Village
Dist. No..'6 0� County.....-..f»:»t':.» or City ci- -"`
�J/per _ (If city, ve street address)
Name of de eased Veteran
, -. (If veteran, give name of War)
Single, married, widowed, p� 3 d --
Sex color or divorced (write the word).... Date of Dea
Age .l Years Months ,,...,...Day Birthplace...,...-- -�' '•••
Cause of Death - --- -----e. / )P
.....
Certificate was signed by .. .. .... ......s M.D.
Address / 5 b
Place of Burial (or Removal) j
(If body is to be tempos i1y Tel in!pace9later)� /:/
Cemetery 19 -)
. „�.,.�—,c,�1 Date of Burial..... .... ...... ...,.�
(If body is to be temporarily held,811 in space later)
Thu Certificate of Death containing the above stated particulars, having been presented to me, fter 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 , and on the basis thereof I HEREBY GRANT A PERMIT e C -,7
t.n ,... v/
/ a (Address) y
th -�- to hold temporaril and the
(Unde er or person Taring charge off-corpse) (Inter,*gore,or otgerrvise dispose of (state bow])
Dated c; 19 (Signed) ""^ Local Registrar
-4'i4*,.�.
bject to
This Permit is gulaeient , unless Removal
removal isand Interment or common carriers in tion) of a whichcase aoTransit Pey to any rmit (VS No.art of the 62) iserequired. local
cemetery or other regulations), by
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEIRMENTS OR CREMATIONS
ARE MADE
Date 9 7 Jt. 19
(Interment or Cremation)
(N me of Cemetery, rema orium, e c.)
�J 6 `7 6
Section i / Lot No. 4/7 1 Grave No.
- R j
(Su k
ed) ���.� � �" 22 C '_
(Person in charge)
7-
Address f , `_ C
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 DIRECTOF 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.