Shittemore, Esther Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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._.._
Village
Dist. Noct•°S,County,r.JLL1.a ek- -'\. . or City 4.4°�" ....
((�IIf!f c'.ty,give street add )
Name of deceased.. \... � •.••••••••.i. .1...1. . ,E......f.tR1/eteran �'
` Ingle, married, widowed, ,` ((f ,Bran give name of war)
Se4L.Colon'- I'-' or divorced (wnte the word) 'i" Date of Death... .. / l • •
A
�- ... . ) •
Age � 1' • years i.
onths Days Birthplace
Cause of Death...i.w'-',.. ,, f?e€. —.,-ek A.... ._
Certificate was sfd by .. .. .. M.D.
Address ``- .,................ . ..,�, 4. ... . �-
Place of Burial (or Removal) - `13e l
(If body is t -2emporar held,Hll in Up I er) i-
Cemetery ....4.:.,..(, ,, .-+:..... ;.. . Date of Burial `
(If body is to a temporarily held,fill in space ater)
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 istration have recorded it in my Lo co d with the above stated Registered
Num , on the basis I HEREBY 0GRANT A PERMIT ,-�" s',"
to
� ),�j: f
q�._tw) f f (Address)
the �'` to hold temporarily and the body.
(Undertaker or rson having chart of corpse) Inter,remove,or erwise disnoae of(state how))
Dated ...,.. 19. ,. (Signed) ,
r. al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o ^� was 19 K CIL
(Interment or on)
12. i
I
c-
_.
(Rase of metery, Crematorium, etc.)
Section 4 'ot No. Grave No.
,2?(Signed) G+�✓. a ... � C.
(Person in charge)
Address - / e / c.,...,
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 OFFENSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.