Hutchinson, Jane Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Gr 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 DU BLACK INK Trce-n Registered No.__._..,/
,-'/' ,) Village
Dist. No\,.).4Po.I. County................... or-City ...
(If city, give street ad Be)
Name deceased. . ... . ... •. . a eteran fn—(�
//�� // 44 Single, married, widowed, 1 veteran, give name of Via')
Sex. .... . ..s Color.. .or divorced (waste the word).. Date of t1 � .19S.4
Age 69. ..Year Mon ,,1..7 Days Birthplac
I yei4,44... 1 ,-,
Cause of Death../
•
Certificate was signs b ,. M.D.
Address ---2/1... ..... .., r
Place of Burial (or Re o a1) ... ..... .. . �?-. .. ,... �. .. .
(IL body is to be emporart 1 �il vac t ) /
, e,
Cemetery ,: c.£ � �.tl....(/� .. Date of Burial.... . . . . . .. kly 19 . .
(If body is t temporarily held, fill in space later)
The Certificate of Death containing the above stated particul s; ing 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 . cord with the above stated Registered
Numl,rid a basis t reo HEREBY GRANT A PERMITto ,,
A , -I �i�', t�� 4Na�)n L / Address)
the...„ i.. lrl.G (12-e G.I.r to hold temporarily nd .. . . . the body.
, d rtaker or n h ving charge of orpae) ter, move,or t r isnose of[state how])
Dated`.. .. ',...4. ...19,.J�.—�p (Signed) Ti
• ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to any part of th bject lal
cemetery or other regulatiops), unless removal is by common carrier, in which case a Transit Permit (VS No. 62 a requi
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES'ON WHICH INTERMENTS OR CREMATIONS
ARE MADE _=ec. • Jer,
r
Date o f was,- .-'" 19 ' 7a
(Interment or Cremation)
)
c. ,
(Name of Cemetery, Crematorium,/etc.)
Section Lot No. _Grave No.
(Signed)/ ?LHr -� f c'e > ‘'
(Person in charge)
Address �. � C < L �cr ` c�4._
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. Loc gistrars are re—
quired, under penalty, to re violations thereof.