Mathews, Elizabeth Form VS.si• 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.-::::.G/........_
/,
Village VI ,-
Dist. No Z ..County...h.l..G zs ./. os ::.�: :. . : -.�--
(If city, give sift address)
Name of decea((sed..C{ N ':�e. ... 4r ",�I..--LfC Veteran -/ le-�?
!� Single, married, widowed, a (1f veteran, give name of war)
Sex. l .Color 474-4It-or divorced (wnte the word)..d.',4f(...t,--` Date of RDeath ff 19
Age.... ? rs �,.... r. onths $.....Days ! Birthplace..�1.,',,-e .Q•-Z,GG: j., z t
Cause of Death. .4.e. s ..�lL .:2:T.1,.4 . `u:..rt
Certificate was sip* y..�t-:' ��i.. . .. 'y .l�`.:.. a� zr... M.D.
.
Address ad 1.::�. 4°rz..4�1}4 C{ '..1� �' �'u'�
Place of Burial ( Jr Removal).. .. f ,,. .
(If body Is to be temporarily h d,fill in space 1 r ( . J
7yy
Cemetery...2. e..,•:4z..-k..- 't. ::tr -.'-.4 4c' Date of Burial..4r ,� 19L `-
(If body is to be temporarily held, H11 in space later)
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 tor registration, have recorded it in my Local Re rd with the above steed Regi
s
ter
ed
Number, and on the baa V 4c-Pe-yHEREBY GRANT APERMS/ l : r4,..e. `G.?Mf z
to �.: ‘� ��/• ' •#�� ��'
the G..L'.L�� G.li.,.. . .. :�G..- to hold temporarily and . . :; .14,E the bod
( ertaker or pe , having charge of a rpae) J ((Inter,remove,or ot7grwise dism ise of[sta ow])
repel �Jf.+4a:R.'.T.s !L! t�.,7 ? L
Dated.. i' �?l" 19..L:..4 (Signed)...:.;/ . sy.. : t... ..
Locar Registrar
This Permi /s sufficient for the Removal (and Interment oe Cremationn)'o#i� /to any part of the Slate (,abject 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 P )N IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o 19
(Interment or Cremationy
�/JI/qq�q',A, / (Name of Cemetery, Crematorium, etc.)
4* - -0,-1 5414-
Section Lot No.f 1Q Grave No. !
(Signed) /Z�✓_._. L`Gi"L2�
(Person in charge) �—
Address 6,Y. L( ✓-°
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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 OFTNSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.