Underhill, Minerva Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 CERTIFIl?ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No—
Village
Dist. Nol...6.59...County...4-1.20.-2t.4-e---e--(--= or City
(If es y, give street a reeFL4
Name of deceased.. ,e,.._,z)„,e,„te:_e_/ Veteran
Single, married, widowed,
(If veteran, give name of War) z
Sea.Colorth ___,..or divorced (wnte the word) 44--., -;4-1. -a, Date o eath. ./-- A, 19 !--.5
Age. /
?
Cause o Death. .
..•- .
,.-
Address .
-A '*-37'
Place of Burial or Removal) x_e_f_Acc-e-c- 4- '%., -(,-,-,a- - j- c2..P
(If body body Is to be orarily heldLiS1}n space e )
Cemetery ..,.-411c,-,1-e-' 4-/
00
Date of Burial /- 3 i—
(If body is to be temporarily held,fill in space later) 19.44
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 Record with the above stated Registered
Nuey, and on ebasis-thereof t-I-IEREBY GRANT A PERMIT
• (A6d -, j lir
th 62-4ste4- to hold temporarily and the body.
(Updertaker or person having charge of cprpm) (Inter,remor-I .er76e disnose of(stetahow])
Dated 1 - 21 19..4.q (Signed) 4 ,1 .
. 1 Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of ••• . t• any part of the State (eubject 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 o7-7,7✓ was 19
(Interment or Cre tine)
/r-2s. K-?: C ,,
e....0--k,..- ,...--2.,..,....-, \.....,__C--"-Z-j)2-c...,__f-j ,'
( ame of Cemetery, Crematorium, etc.)
Section No. Grave No.
(Signed) a_.
(Person in aka ge)
Address Z' 6 — r-% `'''!
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.