Carpenter, Jennie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. l3 /N
�, Town, Village Registe N .
Dist. No. ��� County 0... ) or City
(If city, give street address
Name of deceased Veteran ..
(I veteran, give name of War)
l-- Single, ma tied, widowed, /
S � or it
(write the word) t, . Date of Death�i�y !.... ..... 19 7G _
Age 9b Ye nths Days Birthplace i _
Cause of Death
Certificate was signed by... M.D.
. ..................:
71
Address /J \.. r
Place of Burial (or Remo al) . , �Q ... ((V��
(If body is to be teporarily helAs i in spateel later
Cemetery 2.--� re!-7:-... .. >,.....:. Date of Burial 19 7,
(If body is to be timporarily held, fill in spas ater)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after reful examination, the
same Appearing to be COMP TE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have corded it in my cal Record wi the above stated Re istered Number, an on the b sis thereof I HEREBY GRANT A
PERMIT /
to V �. - CY ,
(Name) / d�ressj ,�
the ti ,rn to hold temporarily and the body
- (Unde ker r perso having charge of cg�pyte) (Inte , re rive, or otherwise dispose of (state how))
Dated .. 19 ((� (Signed)
This Permit ts�Sufficient for the Removal (and Interment or Cremation)of a body to any t of the State (subject to local cemetery or
other regulations), unless removal is bycommon carrier, in which case a Transit Permit V�s required.
( ) 9
FO'ltM VS. 61. (RF:V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of a'4:146141‘ks 19
(Interment or )
vize 1/ '—
(Name of Cemetery, --The.)
A/4 74/tom "
Section 627 Lot No. 67o Grave No. /
(Signe( ,
(Person in Charge)
Address We*,"<" �'
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 UNDERTAKE
violating the law relative to the return of permits are liabl424
a penalty of NOT LESS THAN FIVE DOLLARS NOR MO
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.