Fish, Cornelia Form V&EL 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..3_0
Village
Dist. I':' SD41 County.....IYv,MA or City
ta � _ � (If clay,glue street address)
Name o:� _ceased +j't'p, ` /"� Veteran c4
Single, married, widowed, i (If veteran. give name of War)
Sex.a. ...'.Color or divorced (write thgword)...W.t. ( of Dea / 0 19
Age a.1 Years eo ths.,......,j.s�, Da e...... ..Cause of Death ,0.. ...,_
Certificate was signed by ..�:.h n..... hM.. CIAAA4 M.D.
Address /44.4117714m.
Ou-4
Place of Burial (or Removal) .
(If body is to be tempora h , 11 In spa let )
Cemetery /�.51'1/Y Date of Burial L. 195;
(If body Is to be temporarily h d,fill: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 Re d with the above stated Registered
Nu , and on theskasis EREBY GRANT A PERMIT )71'QL
t0 / ) (Address)
the to hold temporarily and the body.
(Und ker or person axing charge corpse) (I�er, re or othe se dls,ose of[state how])
Dated . .. { 5. 19.5 j. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the Mate (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a l ransit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PF(FMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
2 C'__.2,k (,
Date of •71 fat<!!/ was'/. tIt /3 19
(Interment or Creii&,41Arn)' ':71 /
. -
•
(Noe of Cemetery, Crematorium, etc.) /
m
Section Lot No. Grave No.
signed) ,f /�Lhf" t'> 21
(Peraon in charge)
•
,ddress V � � � �il. �
'c� t' .�; 5C
-'
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.