Ramsey, Viola Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 Registered No.__.a..Y.'
Coup Village
Dist. No ��� ty..._...�!.�':�?:�:c.� or City 4eIe-Atr,,:,...,-/414
(If city, give street address)
Name of deceased 2 1..71pp L r 3� Veteran ..-2:;-a---
1,,y Single, married, wi OVYed, ��jj� (!1 veter . live name of War)
Sexy�.t'�r�J.�c�e.Color. .or divorced (write the word) f (t? Date of_Death....
Age 9..,5 Years e Months.,..... ........Days Birthplace..../.....; /..
Cause of Death... . .. . 41-7ii -'-E4,,.
Certificate was signed byw .,... a:uc1.-. �. M.D.
Address .�.r
Place of Burial (or Removal) • tl7. ,c�c.kers-zo h
.7..... . ..,. ............
(If body is to be tena,r�arlly fi in space later) a
Cemetery / .??� i✓ rc.a,. ��vt ate of Burial 19
(if body is to be temporarily held,fill in space later)
The;Certificate of Death containing the above stated particulars, having been presented to e, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbs{ on F Zt
h f I biEREBY GRANT A PERMIT
/,e i ) ~"" (Address)
P
the / ¢• .aLst -,+x— to hold temporarily and the body.
(Under er orperson having charge of corpse) (In r,re ye,or p9erwise di nose of[state bow])
Dated 19 s`S (Signed) �!C
Local Registrar
This P rmit i sufficient for the Removal (and Interment or Cremation) of a body 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 SEXTON OR PERSON IN CHARGE OF
PREhfISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o. r was r. 19 6T-r-
(Interment )
1.(1-4-,i6t-d/111.-..-"‘ -L7 A-42‘.-,
(Name of Cemetery, Creme to ui etc.) I
Section . Lot•:No._ Grave No.
(Signed),�j2.i"t0.—�h4...- c,4/7.114f
(Person in arge)
Address 6 L' � 11� / � >✓
C, e-4. .
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 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.