Robinson, Harriet Form vs.(IL 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._ ..(...._.....__
- �(� Vtlag-€ iff:11.4...Q._a_v„
`...7County....• .L.'..� ::a. L-A.. oFEty' j�4s4
Ihst. No.. `
(If city, give street a 9s)
J
Name of deceased :�. .1.I�7- E �.A.'. •S. f�J Veteran
r (If vet r give name of War)
( 1 Single, married, widowed, \\"
r S C7. to (,.or divorced (wnte the word). L/ 'P ..Date of Death �� 19.�V
Age. ... . ` ..years »...Days BirthplaceC f
Cause of Death..,•.&: .r. . ..(.�•. '�. . ... :�.3..1' '`�"
Certificate was signed b ..
.' :.- -;,-?((ld--) C M.D.
Address.. ..�.�,..M ., . .. ..
Place of Bu ' (or Removal) . .
(If body is t e porarily hel LT In'lc tey$� 1 Y
Ys' P--1- Date of Burial E
/ ..,-.
(If body is to be temporarily held, 11 In space later)
Th4 Certificate of Death containing the above stated particulars, having been presente to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted th scam for registration, have recorded it in my Lo Record with the above stated Registered
N ber, and on axis ff I ERA$ RANT A PERMIT / ' ,a)..6. ,
tor. `., a r.: , G /./.......... .e`. . .. .
tt I m.) ddrese)
the.......... .\ ,- Pi' - L. to hold tempora$y, n( t e Ody.
ZUn r ker or person having chariryy��of c rpae) Inter,remove, tithe se dig ose of[state how])
Dated 191 ..,(,- (Signed) ze . r
,._,.....:
Local A
This 't is sufficient for the Rem al (and Interment or Cremation) of a b dy to any part of the State (.abject to local
cemetery or other regulations),unless removal is by common carrier, in which case a ranut Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date _.. awzi_ , 19
-1244
(Interment o )
/7)7 .' ......_.
: -.4.1-CL 7L-4-.0,--"' (11.1.--..--- --
(Name of Cemetery, Crematorium, etc.) j
!
'7
Section ! Lot No.1 P Grave No. :1:---_
w
(Signed) G�....�A�'C�" eldrZ/'2i 7
f (Person in chaq)
Address f? L (1 ,.-../ .-''U°���� e
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.