Huntington, Edith Form VS.AL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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._.../_'. .`4
Village
Dist No County.......�'�` rc-?-- or City ...,.�& — -6,-
4 _T (If city, give street address)
Name of deceased rani W.i... -W.-d--fj-4,37 / '
Veteran
Single, married, widowed, /�' � <lI veteran. give name of war)
Sex Color or divorced (wnte the word) ./1 / QDate of Death „�.4?-7,.... ..19
Age Years:., Months.. ...Days . Birthplace../3:x? .c tx....,.....)7• y %
Cause of Death in r4 '-i h c-4-- :f-r rz:c .
Certificate was signed bya:e---' M.D.�' ..
Address �. ....... .... 31.:.... ..
Place of Burial (or Removal) / ou'Yl .. = -r e �., -�'.
(If body is to be to o arily held,fill in space later)
�. ....11 Date of Burial ''a ..:u- "I 19 '
Cemetery " ' '�'�
(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 ter 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
Numbery%5 on basis the HEREBY GRANT A PERMIT Y Lj
(Address)
the :4'...G:(-4 .1(..-.., to hold temporarily and.. -a the body.
(Underta er or person having charge of corpse) (Inter,remov ,or othe diemose of[state howl)
Dated :..- 7 19 (Signed) : .. e-U•:t.
al Registrar 0
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to a 7 past 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 SEX'iUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o was 19
(Interment or on)
(Name of (Z? '
Crematorium, etc.)
Section Ldt No. ( 7// 1 Grave No.
(Signed) 2^�7/��,,•Zs r
(Person In charge)
Address 0
Person in charge waist 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 OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.