Roberts, Isabella Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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..;.3 A.
IDli
3294 Village MARCY
Dist. No county or City
_ _ (If city, give street address)
Name of deceased 7)o�E/C0s -�- '9 -- -.149 Veteran
Single, married, widowed, (If veteran' give name of War)
....Color....jl�a... or divorced (wnte the word) ate of De r. .�
Sex......, . .e �tr 9�
1
syle
g , as., vionths..F.... ...��D�a�s Birth la G{�
Cause of Death...: .. ........... m-dic.O., Q w/d4lr U1(
Certificate was signed by Plk. 4f .. . M.D.
Address �1 H.
s.,/. .... . .... .. %'�
Place of Burial (or Removal) �.q.�►�n Q
A�� a -�
r ‘..!. �
(If body is bg teinpora h d,fill 1n spacy..ater)
Cemetery. .1,...* VA4sktib ...Qp.%.‘‘A Ih ate of Buri a�..�.+�.�t.LA '1. 19 .
(If body is to be temporarily ,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
N m on the.basis thereof I H EBY pRANT A PERMIT '
to. .4.y.h.. s.. c ... to ma,X%*% .115.t.s< r.......... % 1 a.l.. At►. \ t 5.9.~1►t 1`
O �__, (Name) `` - (Address)
,the .a.1 .i io`t.4Zi to hold temporari d +�,).sA-:V+v the bod .
{ ( dertaker oqr,person having charge of corpse) (Inter,remove, of se dig state how])
D°ated,... Ott..4.AktR AA .4...I 19..6 (Signed) ... ... .ea:.4.6.C___,
Local It
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Mate (eubject 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 of d .- c-,.-J was 7 19 C.
(Interment or Cremation)
(Name of Ce etery, Crematorium, etc.)
4 -CZ-,cis,..
Sec ,ot No. Grave No.
(Signed)
( on In charge) '-"P"....11614
/aIrmo L, � V
Address V - 6 . b U 1
A .
Person in charge rust return 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 cords
"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 OFF'RNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.