Dunn, Mary Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ir 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 CERTIFicAlj,•OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No— Li
Dist. No ..t.-f.County... . .. . . . ... ... .. oVriCllitye ---0.-"...Y
14..1-21.)(1.11,#etelcivr
(If city,give street address)
Name of deceased...:2...):4.-.)...eW.,..,h,,•44 a ,-.). .A.:-4„.1/4., Veteran '••••?1,,,C)
(If give name of War)
Single, nuveteran,
irried, widowed, ,
Seailds...4&Color..1,.4141.t.4..Tskor divorced (write the word)14:::t..4,44-7/..4.,9:-e-.L.w.Date of Deati....;ft- •,` ../.4,19.47,..
Age a'.o Years Months 4,s -,,,s.a.„, ,
Birthplace...N-:&,. . • • ..• ...... •••• • ••:14.
Cause of Death •• . , M.D.
Certificate was sign—ec-Ty.:Cdr .
. ... 1P...4. , 11.4
Place of Burial (or Removal)
(If body Is to,littemp ly Ile ,fill In space later) ,i..1
Cemetery. . c.-Yr.. . .. .. ... .. Date of Burial CX ...532.4...- I.•W 19/Q
(If body is to be temporarily bel 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
Nu , and on the b In: HEREBY GRANT A PERMIT
to .. . -Ire • ' '‘. 5 4;, 1-4-2) cx-r,-,...NAz,...4. 9-ft-AANTN.Q.C4L,
A,,,,,L0.1. ., ; _ (,___ r) - . calecak (kddress)
the .. .... .......- to hold temporarily and . . . the body.
ertake:1279aving charge of corpse) 0.4).2zve.
Merjse-etis=!iMeLa....)r]k
Dated 19.1:: • (Signed). 1
Local Registrar
This Peron is sufficient 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
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
1 /
Date of ;,` )- • 7 was ( " 6 / t� 19 G )
(Interment or Cremat )
(Name of Cemetery, Crematorium, etc.)
Sect 0 Lot No. `3 Grave No.
(Signed)
RC-76
rson in charge)
Address 42 crzY t A
Person in charge oust 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.