Jenkins, Martha Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ur 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 CERTIP LATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No. .. .1_.
Dist. No r f C 1j �County...11 . Village
or City iG/
—U4
4 (If
r W city, give street add s
Name of deceased111L Veteran
t) Single, married, widowed,., +`J rA (If veteran. givG name of Wu)
Sex Color....Ld or divorced (write the word) W Date of De fi 9••�j
Age Years. .Months D yjs Birthplace "`.�.�� / I
Cause of Death 4L.. t.. '—Y` Y. ..-,1�- i��
Certificate was signed by.. J2_ Ck----4.-- M.D.
Address ''1,4/-4�. " k ' '.l ,_"
Place of Burial (or Removal) �S..G+..1.A,�.- Z.... ,..„07
(5,7f CP --c.--- 1 / '�l y(If body is to b ore ly held,fill I s ace t ) 1
Cemetery .. .,a...--a&C., ( � '"f e, �,, Date of Burial � 19.. ...j'
ti
...
(If body is to be emporarily held,ell 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 Recor with the above stated Registered
Num , and on the basis-thereof REBY GRANT A PERMIT f 'j� 77
(N me Address)
the °-x- to hold temporaril and the body.
(Uri taker or person raving charge of corpse) (In r,remove, r othemnee disnoie pf state howl)
Dated �l��l 19.. v... (Signed) 'X1
1 Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (estbject 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`..-Jz‘ -- j was a Lit 19 t
(Intorm ^Er rate oreeelfem}/
(.7":.:7-. e-4,.....-- 7--/es.:.—" ..
(Name of Cemetery, Crematorium, etc.)
Section._-- Lot No. f„c Grave No.
(Si gne ) G �/ ``��^,
(person in charge)
Address d' 0 v` ,,(<.s�� ,�'^�
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 OFF1NSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.