Monroe, Lillian form VS.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Li* This Permit can be signed only by the Local Registrar (Deputy or suhregistrar) 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 F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Regiistttered No. ._., ..
..C..Q./. (,)Q Village 4&- L4
cX'-' a '2/ l''
Dist. No .Couaty.....».� `� or City .....
n,, (If etty, give street add ss)
Name of deceased I' V, ' ''� — Veteran
)� ) Single, married, widowed, (1( veteran. give OLie of War)
Sex T Color �" or divorced (wnte the word) Date of Death... / 5 19 2
Age 5. 0 Years Months Days Birthplace -= r�'t ......t 91•2;t
Cause of Death ,Qi...v.....
l
Certificate was signed by ) ,...PT `'4' M.D.
Address :R-�Vul
'�• •% Z
Place of Burial (or Removal) Q-�t-)""'t t "J
(If body is to be,arp arily held,fill in space later), /
Cemetery ,� ---'v'SJ.4 (,. `,. '1-(- 1.. • Date of Burial / 19 6-2
(If body is to be temporarily held,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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, d on basis thereof I HEREBY GRANT A PERMIT AtiL o��
(„/
/ �, ,�ddress)
the -: to old temporarily and �"""�j;'� the body.
(Undertaker or person having charge ¢grilse) /Inter,remove or therwise d}�oae of[ fate bow])
Dated it.� ?:r:}r. 1 7 19 6 - (Signed) t QY,I'i-�L' -.'QI/ G/f-//L_'If1/t
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any port 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.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
l Date 9 '_ , _ wa� �A:,E/ .:://X 19 .i 3
(Interment or C g &
(Name of Cemetery, Crematorium, etc.)
n
f
Section 7 Lot No.___ Grave No.
(Signed) _� • L �I C ? '�f�
(Person in charga) v
i
....,:zic
Addres‘F u 1.../p L „.ti,"" - ,z.
Person in charge mist return this Permit to . ,
the Registrar of his District within SEVEN (7) DAYS
frcan 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.