Cornell, Laura Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration Dis 'ct (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER Cc ..—
ATE OF
DEATH, LEGIBLY WR IN DU LE BLACK INK. Town Registered No— ..... ..... .. —
Vitr0
Dist. No 3—.“ wa, .. . .. 0.1:S.ItY,
(If r',y, give str a dress)
N e of dec 0.ed ''..---II V tr‹,./et- ./Cc 6,) i-i f".2 1--(--- Veteran
1 ii,...skSingle, married, widowed,
Sex. ' IAA/ or divorced (write the word).
ay_
If ate of Death
ve a give name of War)
4. 19.Vf
Age h) ATVS.. 4 .t„Months.. .Days I ,Birthplacs , • -
Cause of Death .RAT.Ne U
Certificate was sign 0. . .., .., , M.D.
Address (
Place of Burl. ,r1 -moval)
(If body is to .iiiprarily held, 11 Ii spate r) 1116.
Cemetery it -4------1,,_ 'n Date of Burial 19.6..y
(If body la to be te .porarily held,fl in ace later) 40• 7
The Certificate of Death containing the above stated particulars, having been present . to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
ve ccepted the am for regis tion, have recorded it in my Lout,'ecord with the a ve stated Registered
and on s thereof HEREBY GRANT A PERMIT dr •
, - - s_._--
ame) Add the
the to hold tempo St and the body.
I
ter .r person haying chargr o ) .A0 (Inter,remove, o end ,ose of[state bow]
(Signed). /
e-', • al R
rt. Pe ,t is sufficient for the Rem val (and Interment or remation) of a It•.y 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 SECTON OR PER )N IN CHARGE OF
PREMISES ON WHICH INTENTS OR CREMATIONS
ARE MADE
Date o was 19 f� 7
(Interment or, tim) ,
•
(Ne of Ceme ery, C matorium, etc.)
Section Lam/ VV Lot No. ' e.... Grave No. /
(Si geed) �t g �� .tiZ `'
in Gear e)
Addres g7I 30.
cv
Person in charge must return this�D6rmit 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.