Mayberry, Mabel Form VS No. 62. 7-68-10M
TRANSIT PERMIT
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
DIV A Transit Permit and Transit Label issued by the Local Registrar of Vital Statistics must accompany each
dead body transported by a common carrier. — San. Code Sec. 13.1(a).
CERTIFICATE OF FUNERAL DIRECTOR OR UNDERTAKER
I Hereby Certify that the accompanying dead body of Mabel Jones Mayberry
Veteran*NO who died in the Village of Amityville
;IF :a:uran, give name of War) (City, Village or Town)
County of Suffolk State of New York, on Nov. 30, 1969 ma
Sexfele wdo ingle`ed
Divorced
Color or rac @gro Age 78 years months days, Birthplace New York and Causeof
-43
ii Death acute myocardial infarction
has been prepared for transportation
astrictly in accordance with San. Code Sec. 13.1, Par.2a as printed with this blank. Certificate was signed by
t Jos. E.Sutton,Jr. , M.D., Address Y 12/2/69
= Date of shipment
✓ Penn Central R.R. _
ii 19 ; Route of shipment .
ti New York City ,�'itie1/�'4''A''G194A.k't
3 shipment ; Point of destination Albany, N. Y. a Vh eA.s/�✓re r,,f,., ,.
,Q Name and Address of Consignee Denning & Stafford
Funeral Home, 41 Glen Si.' Glens
•• �!�� .. pp4 45 9Falls,NY
.°.' (Signature of Funeral DirectorsUndertaker) .. * Reg. No.
Dated DeC• 19 19 69 Address 3095 Hempstead. Tpke.Levittown,N.Y.
3 -Cross out words not applying.
ea PERMIT OF LOCAL REGISTRAR
aDIST. No. 5120 Registered No. 69
Date of issuance Dec. 1, 19
A satisfactory Certificate of Death for above decedent having been filed and recorded in my office. PERMISSION
IS HEREBY GRANTED FOR THE REMOVAL AND SHIPMENT F THE OD .
(Signature of Local Registrar)
Local Registiarof theVillage of AIllityvill County of uffolk
�Clly, Village, Town) '
State of New York.
N' Only the Local Registrar (Deputy or Subregistrar) may issue a Burial, Removal or Transit Permit
Mr Detach here and give part above to escort or attach to waybill if shipped by express.
ENDORSEMENT OF OF SEXTON OR PERSON IN CHARGE OF PREMISES ON
WHICH INTERMENTS OR CREMATIONS ARE MADE
...,..._,
-.-/-r„--A
Date of was
.4 e 'ent or-Cretnatior+.
id
(Name of Cemetery, ( islioniongSir,.)
..„4 /- Icto--e- . .
Section Lot No. /01 Kiave No. &
_
,
' I
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Persons in charge/must return this Permit to Registrar of his District within SEVEN (7) DAYS from above date.
If no per on is in charge, THE FUNERAL DIRECTOR OR UNDERTAKER MUST SIGN ABOVE STATEMENT, write
across the e Permit the words "No person in charge" and FILE PERMIT WITHIN THREE (3) DAYS with
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 required, under penalty, to report violations thereof.
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