Flewelling, Arthur Form vii.ei. 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.
,,,../
Dist. No V- ---7 County...T .. . eqCity Vithrge -- ..,er -"--•
4 — , , (If .ty, give street address)
, /
Name of deceased.C- .1--- t kf:-C.I 1.--Ce....44...... e”eteran ------
..
(If veteran, give name of War)
_./ Single, married, idowed, .. _
Sex 7& Color 1--e,h ..fgr divorced (write the word) --1-1-1... Date o;fath 9 - ,2-e. — 19.1.
Age .52". Year onths.....a.4-- Days Birthplace. -3-, dttne-re.,,,A.
Cause of Death-. . .. .... ..• . . ". 40dt..;(...-....C--.44..:Ae0.1....4.4.-P7A-zo.,4.
40%.0 _
Certificate was signed by elD-•'''.■-• . •s....1--:-.114.• . M.D.
Address 3 -.'- 1 74-1,..,--,—;—•.--- 3-4— es ;-(--,M., 7,7 2
, , '
__-) .,
Place of Burial (or Removal) ig--a-i........):4_. 45,4e-t-s.,‘,-.4"..i..4....-
(If body is to be temp9railly held,811 in space lat r) ..
L.Cemetery.2. .,.. '''...*--t'f' 9 4— -.4" Date of Burial. 9/2... -2- /. ..' .b 19
(If body is to be temporarily held,811 in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, 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
Ni(Lr, tnd, on .,.., basisribereof I HEREBY GRANT A PERMIT cz.„4.,..e_e..c.,,,
t 91 , .
i ame) - , (Address)
.ex.14-1-1- -- to hold temporarily and ,r7-f,-.--ifer the body.
(Undertaker or person haying charge ot corpse) 7.-D I er,reive,orrw...4€1.:Ze 'nose of(state how))
Dated 1 (Signed)
Local Registrar
This Permit is 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
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE . (/ L
Date of` .. iwas 196 S'
(Interment o )
rZ11-14/„A '17 '''7 *. ''‘(::;1/1.1:7'4;;' ''s.
(Name of Cemetery, Crematorium, etc
Section Lot No. ? Grave No.
(Signed) 1. ... ..1�'_._ . 99 ..� --. '�3�1�'4
(Person in charge)
Address 0')/1-1 /Pfr -'6?-:a.-e'l' ./.474; '''': /,i-�-�
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 OFH.NSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.