Digon, Anna NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
igr 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. __
Town, Villa
Dist. No,sC.0_1 County 1 _4 or City �� c=/ x-�"�D�
Cf/J
AtIPS .
If c' •, give street a drag '
Name of decease. ,' '
0 Veteran .
i (If veteran, give name of War)
i Single, married,wid ed, •
�� p�� _ r�-
Sex ' ,I s_ or divorced (write the word) ._. -. .. _(��v x ... Date of D ��.? 19_e_c1
Age - GT--! Years _ .__ Months y irthplace •
Cause of)!each
Certificate was signed by � M.D.
Address (7 --Lin4, ,/'--. ,t
Place of Burial (or Removal
(If body is to be ora eld, f space Bite
Cemetery ,ph Date of Burial /772(h) 19.cf)c
(If body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the sam appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regi ation, have recorded it in my Loctal cord with the above stat Registered Number, and on the 's thereof I HERE-
BY G PERAlIIT
to -
(Na e) (Addy.se)
the ....... . __. to hold temporarily and . .. . the body
(Unlertaker or person having charge of corpse (Inter, ) rot wise isp se o state how))
Dated /— t71' ( 19 G (Signed)
Local Itegistra
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part o e 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.
FORM VS. 61. 1 REV. 6/631 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of -/��'r'Z h as h '19 06
(Interment or C�eitlat`
CW- 'V
(Name of Cemetery, Qso^`atarliam etc)`V
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address /eZ,s
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
UNDERTAKER 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 UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.