Kilmer, Bertha Form vs.41 NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fz 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—_.3 e7,7
�� Village
�.��1 '-'1 r ¢
Dist. No.�(=4 ( County..._ 4«?� or City � a�%
r.... (If city,give it eel t addre 4
Name of deceased ��e .i�,t.f� {
Veteran
Single, married, widowed, (If voter give name of War)
E
Sex Color.. or divorced (wnte the word).. .. ...4 Y.�.e.g ...Date of ath ..4 19
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Age Years Months. Days { irthplace.. .. ...L&ri. )7.7 N.
Cause of Death... a Y ✓.. C..4.....*A.,..,
Certificate was signed by .. s5' M.D.
Address a. �'� 01 '�
Place of Burial (or Removal) 7.l.L.:..1...
� ''�`�.........-psi-Na.. .Z,ciz ,�...2j.
(If body is to mporar]y held,flll in space later) � Y M /f
Cemetery:.. ,.cam �-&-' 41 7 Date of Burial l.�t (� 7 19 ....:
(If body is to be temporarily held,fill in space later)
The.Certificate of Death containing the above stated particulars, having been present' 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, ;o the basis th eof I HEREBY (RANT A PERMIT/1 ' /7'6-
to �,.. .mod-ia. .., ...44:1,.£- .. . a..-..... xf a.. ,1 •
l ) -- (Address)
the .. • •�., i� to hold temporaril and.. the body.
(Under• or person having charge of corpse) (Inter,rem e,or other se Me of�how])y
Dated �. �� / 19 .., (Signed) 1 _ ' -.I�' ar u�.
� � al Registrar
This P •.'t is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 'fate (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 SEX'VN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
4 .
Datet'off-e., ,. _..._.. � p 19��5
(I ferment ors. iWas._______7- .
1 -
(Name of Cemetery, Crematorium, etc )
Section Lot No. —
____—
Grave No.
Signed) C'11=--+42- l C i ‘
(Person in charge)
-,
AddresZ6C ( C__r'--
- :: ,...,/,'"----
,,./Ji,;:------- -- '-,. ',-/
Person in charge Heist return this Permit .
the Registrar of his District within SEVEN (7) DAYS
fran 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.