Green, Marian Form vs,sii. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT •
t: This Permit tan 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._Z.. ..1
2 ONEIDA Village MARCY
Di No....1 94..County or City
(If city, give street address)
e of deceased"`.u-�,�j�s1�c Veteran 7L-Q
nn Sin le, married, widowed, (If veteran, give name of War)
S �t�C g
.., Co1or...(4/`�'` or divorced (write the word).(M.rL � Date of Death 7 / 2--.,,Et. 19..iS/
Age. •q Years g � Months .Z:.�r....,.....Days Birthplace - )-
Cause of Death.... .,dncv.... a .... .. 4 s, ,..t�xi.c0tur<�...aii.7.e44•� �sG .t2‘ktfr(a�.�.cr;
Certificate was signed by `C u
1-ya u� ' M.D.
Address. " .ad.�. . i.... .g.,...?!ts ?-r
Place of Burial (or Removal) �a►i�n,•l
(If body is to be temp y held,IIll in s later) �" 7 19�'F
Cemetery ethAfrA, . Date of Burial .. .
(If body is to be tempor rily held,ill space later)
The Certificate of Death con fining the abov 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 Recor with the ahoy gated7e 'Nu„ ' i . ',on,the bah HEREBY GRANT A PERMIT ���"t M
the r"� to hold temporari y and .... thebody.
(tin. - or person having charge,�t orpse) (Inter,re ore oS otbe incise moose of['tate how])
Dated... ,r'I ..?rG► 19 (Signed) ' lR
�a G �L� D e tit.y Local Registrar
e .. t is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cern d
r`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 INTEBMED1TS OR CRBfATIONS ,
ARE MADE
Date o4 L . 7.. was h , 19
(Interment or C
2>,(1/:,7 G
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(person in charge)
Address -(7 !/ , /. 1
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.