Corkland, Kathleen form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
linage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._1..._..................._
Village 4....".z...e,,,,
)ist. No•- .s/ Count, or-Gity
(If city, give str t address)
Jame of deceased /� Veteran ?I-'
��SSi,ngle, married, widowed, (1 veteran, give name of War)
> olor o"- divorced (write the word).. Date of eath..� 19 d•3
k.ge v7i Years Months Days Birthplace.-ca r—¢-' ?.---c�-,...27..'.y..
:ause of Death a., t.les:.,t.✓ .7 •
:ertificate was signed by a ,rl-•, ..a.. 1 M.D.
Address 4 y.. 7'X _
'lace of Burial (or Removal) .
If body is to mporarllybe fill in apace later)
"emeter}tp--=r .A.-- 71 1 Date of Burial 4 19...&.3
If body Is to be temporarily held,fill in space later)
Che Certificate of Death containing the above stated particulars, having been presented to me, after careful encami-
iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Juml7virgi the basis thereof HEREBY GRANT A PERMIT
( =) • (Address)
he to hold temporarily and the body.
(Undertaker or person having charge of corpse) t, (Inter remove,or other�wwiise4sa�ose of[state bowl)
)at a 194N.3.. (Signed) ,. .... . —. ../..' .. .
Localal+Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
emetry or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
INDORSEMENT OF SEX`iUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date Z 19
(Interment ortremal4a►)-
ki (Name of Cemetery, Crematoriue to.)
Section Lot No. Grave No.
(Signed) c.21:,"/„ �'�-
(Person in charge)
Address 1JL2f
Person in charge Gust return this P t 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.