Belden, Catherine *arm vs.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTI ICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._ . ,/
��� Village
v ��� �/l
fist. No..� �Corm ...�a2��.�- or City .��..
—. ) (If city, give str t� address)
Name of deceased - .... ...••�� ..... .... .... Veteran
Single, married, widowed, (If vet an give name of War)
Sex....f Color...//// on divorced (wnte the word)..� ( Date o ath �19C Z
Age ..��...3 Year *onths D " ��place . ... .. .. . . le.. .. .... ,
Cause of Death 1.7 .... ..
.rlt
Certificate was signed by . .. . ... v M.D.
Address •
Place of Burial ( emoval) �? cam! � �� .y..........:
(If body Is to be to 1) rily held,fill ins ce ater) Z
Cemetery ... �.ri. � Date of Burial >.5 19
(If body is to be temporarily held, 111 in space later)
The;Certificate of Death containing the above stated particulars, having been presented` o me, aft r 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 n the b is thereof I HEREBY GRANT A PERMIT
to • ,. / ... .,,,--t-e-7 , 74-e4 2-7,/
• " . (N (Address)
the to hold temporarily and... the body.
(Thule er or pe a reel charge of corpse) (Inter,remove,or otherwise Mims()of [state bow])
Dated 19. ....-•- (Signed)...7Y}.hl.as... �:ex
Local Registrar
This Permit is su dent for the Removal (and Interment or Cremation) of a body to any part of the State (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 CREMATIONS
ARE MADE
Date ✓A. c'-. C was C r 19 % r
(Interment or Cr+'� cqJ'2")�
7 . 7/.
i :O4L:r.:,
(Name of Cemetery, Crematorium, etc.)
j
4
Section Lot No. �•o / 7 Grave No.
(Signed)^7::)---6L-f--4.—S ---a41� -( (
(person in charge)
Address rf y „ .-te2 i
47e27 --* --ze:/
Person in arge hiss 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.