Jarvis, Baby Girl Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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....
Village /��
�j
Dist. No County......».���»vc.�..»rc.. or CitY • - �' .. Z
�� (If city, give street address)
Name of deceased 1 ! e--r ..f,--- z-7--' Veteran
( (If veteran. give name of War)
Single, married, widowed, ,;
Sex Color.../:! or divorced (write the word).. s5�7� L':Z:t. !..Date of Death :, ° a .�/...19
Age Years.. Months... Days Birthplace
Cause of Death .-ftr.,-4-......! .L . ...,,_
Certificate was signed by fir • M.D.
Address
Place of Burial (or Removal) .4 '21 A ,.„.-c.d.,.... .. )..
(If body is to be
tempor I held�s a at er)
Cemetery ��� - :��{k� �4-:.;1.z Date of Burial - 2- 7 19
(If body is to be temporarily held, fill in space later)
Thn 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
Number and on the basis thereof EREBYNT A PERMIT
to .4,4..:.Y.L.0. .t1"...�;y .1-:--7 j,4: -`r-- ... .C..o.. !
the /-/kii-d --aa��1 �" (Address)
N��' to hold ten'orarily and. the body.
(IIndertn orr person�,J�arias charge of corpse) (Inter,remov ,or othe disrws of state bowl)
Dated , c ' 19. .:3. (Signed) :••
al Registrar
This Permit is sufficient for the Removal (and Interment of Cremation) of a body to an part of the State (.abject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
•
ENDORSIidENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREIMATIONS
ARE MADE
Date oA'L"w 2-r+--4-.---e- was s 'Z r 19 _,.3
(Interment or Cremation)
Y � "
(Name Cemetery, Crematorium, etc.)
047
Poo ?l�-G ,a v s '°� ,�,� A, r
Section Lot No. /3 Grave No._4 f 3F/
(Si gnela c�.� G •
(Person 1 n'charge) r
Address (P d , ` G 0
Person in charge must re this Permit 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 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 OF /ASE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.