Granger, Ruth NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t. 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, Village
Ith
Registe o. ... 7-
Dist. No. � ////,,�� County G^ or City
(If city, give street address)
Name of deceased f,.1.4.27t, 71/0- art- - Veteran
(If veteran, give name of War)
Single, married, widowed, // �J
•
Se or divorced(write the word) . . Date of Death l .19 ..1.•..�'
Age.. .,... Year onth Days Birthplace .
Cause of Death
Certificate was signed y 44-4-ZL. M.D.
Address 4V-..5 Nf4cE'-& `�/
Place of Burial or Removal ... .. "
(If body is to mporarilyvh d, ill. n e ater7.--
Cemetery .,L`f7"a.. V Date of Burial :Z3 191(
(If body is to a temporarily held, fill in pace ater)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY AW, I have accepted the same for registra-
tion, have corded it in my ocal Record wi the above stated Register Number, on the basis thereof I HEREBY GRANT A
PERM[T� v I
me) ( ress)
the „1 to hold temporarily and the body
(Undert ' r or person having c arge of o se) (Interhr,emove, or otherwise dispose of (state how))
Dated i ' ..� 19 �......... (Signed) . ,�
This Pet it is sufficient for the Removal (and Interment or Cremation)of a body to an part of the State (subject to local cemetery ot
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
100,ItM VS. 61. (RN:V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o was I 19��
(Interment or Cremafn)
•
ame of Cemetery, CrrefatQrium, etc.),
Section Lot No. / Grave No. /
(Sign /6
(Person in Charge)
•
Address '' 7'#-/ 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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, 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 required, under
penalty, to report violations thereof.