Bingham, Deborah Form Th.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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.__.._..... _
i n ® �
Dist. No.S E /County. Ct.) ............».... or Village c_.�C -.�
. (If city, ve street address)
Name of d eased iA.- .? Veteran
L, Single, married, widowed, - Or veteerran, give name of War)
Sex , Color or divorced (write the word Date of D th._... 5 "— 3a
Age .. Years Months A .....Days_ Bkthplace
Cause of Death ,�1.
Certificate was signed by e.�4,� •:e �� M.D.
Address 'a :. -
^��=�
Place of Burial (or Removal)
(If body is to be temp rily hdl is s ce later) �- f
Cemetery..... ,. [ t of Burial ... 19 r
(If body is to be temporarily held, in space later)
Thq 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 a ve staa d Registered
Num and on the basis t .f I HEREBY GRANT A PERMIT 7 f
to F
Q ✓ arpe) ( areas)
the ' ::3:-L. :, to hold temporaril and the body.
(Undertaker or person having charge of corpse) (Inter,remove,or othe dienose If[state how])
Dated --- /,3 19. ..Je (Signed) ... e..l. ^-,v"'/N.,
IA Aegletrar is
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any art 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 SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
-.__-
Date of i was 3 % 5 19 a
(Interment or Cremation) J
'
(Name of Cemeery Crematorium, etc.)
Section -4 Lot No. 3 v Grave No.
(Signed) u2Ai
(Pe on in charge)
Address
Person in charge must return 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 m.NSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.