Wilcoxson, Grace Forma V8.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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—.._..__....._._
3301 ONONDAGA Village SYRACUSE
Dist. No Con or City
+ (It city,give street address)
Name of deceased... ../t�� - //.. .... Veteran
` 'j Single, married, widowed, 1 (If veteran, give name of War)
Sex Color P d or divorced (wnte the word) 7 Date of eath....,.�. 1
Age , S ye r ..�- Months.../ ....._.....Days Birthplace. .... � ../.:`(J
Cause of Death. . .
Certificate was signed b M.D.
Address ..�.. ... ... . .. r;
Place of Burial (or Re oval).fill s / _
(If body is to be m rarll he , lat r b C�
Cemetery ' �� C,�'�? ' c Date of Burial T!! 19.5 6/
(If body to to be temporarily held,fill In space later)
Tht 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 gam for registration, have recorded it in my Local Record with the above stated Registered
Num ..� �j} the b th/HEREBY GRANT A PERMIT
to �..
(Name) (Address)
the to hold temporarily and. the body.
(Undertakpr7 person having charge of corpse) ( nter,remove,or othe se dispose of[state how])
Dated.y7—,(. 19..5:.(cr (Signed) 222
DEPUTY Local Registrar s /11
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 CREMATIONS
ARE MADE C..X..e.ec.
,- � 'fit
Date o �✓y zc _19(...6-6-
(Intermen or
/77 ''- < L'9.•2 .) 4—
**-- -.." 1/e../ ,•,'& ' '
7NamYCeme te Ceme te r ematorium, etc.) >
Section ‘---'" Lot No. L-'" Grave No. '..
ey /
(Si pied) ��2.Z-4 - `-kJ 67o',ZG fi
(Person in charge)
Address (�(-� (�'��///fi %�c,r ,AL - {rS�-..s'
V
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.