Stewart, Jennie Form VS.cL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit eau 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. Z- m
gistered No.___..�..Z,..._..........
J Village ,� �
Dist. No Coun .... �l... .C.. - '�v oc City G(Xx
(If city, give street address)
Name of deceased 1 Veteran
.r I %A), (If Mira give name of Wax)Single, married, widowed,Sexy"'r�// Color. or divorced (wnte a word) Date of,�,,,D,ffath.... d 196 6
Age /I1 Yea / .Days Birthplace..O['-'a'G "`�"w.,t
f� .� Mon s....../.. I-4.y.
Cause of Death f -c:4- do--(-- . 1 .� —Certificate was si ed C1��? � ��/`-�i✓ M.D.
signed by
Address f -4A- AL.41-4Place of Burial (or Removal) `�-4d�� t/ 'J - 1��,
(I!body is to porarily hel lt•in:vice]ear),,
Cemetery por I ,���in (� 1 .0 Date of Burial ` — / 0 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 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
Number on the basis t.`X• H 1.7 GRANT A PERMIT i � ti <\/�
to C /V'A-�2� tJ'v
the to hold temporarily an `rtritriFareas> the body.
(tin r or person baring ebarge_o corpse) er,tfein e,or otle6aose of stabs bow])
Dated - / 0 15L5.(7: (Signed) Y
Local Registrar.
This Permit is sufficient for the Removal (and Interment or Cremation of a bod to any pert of the State subject to local
cemetery or other regulations),unless removal is by common carrier, in which c e a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Ccat..C..- 61,e5i c�te,'C!
Date Of'- J1 • was, _- /el 19 sZ,
(Interment or flowissilhea4
/// • .22/
(Name of Cemetery, Crematorium,}tc.)
Section 7 / Lot No. / / Grave No. Q5
(Signed) et'‘ 7c_ (6
(Person in charge)
Address '> 2-(/� dzi ,.'sy.�`^- l'�-' _ [(�viy
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.