Fitzgerald, Catherine Form Fs.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tT 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 CERTIF ATE QF .
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._-.. ' ...Q
3294
Dist. No County ONEIDA Village
or City MARCY
• (If city, give street address)
Name of deceased... L 71, - 5L2..1,diLds
Veteran 7 - •
n —Single, married,widowed. r (If veteran, given a of War)
SeX .e , ' 44..Color�'�` r divorced (wJ ee tkle word).4�T 67 Date of Death -�' t-t- . 4 C 19 P
Age 4 4• ear ..td.cog.g Month g..»...Day t Birthpl 4 vi ...
Cause of Death_ ...�
a.. 4°,:ex .e p C It- ,�.it-e at 0-t .9.ct-�' -P- alx' ..... sal,
Certificate was signed by l..t)L t...: ,. M.D.
Address is 4,4 ` 1 e•• / qL •%
(jiff
Place of Burial (or Removal) ,•„
(If body Is to be to rily held,flU in spa ater) 'l
Cemetery ... .. .. . . ....,.....a. Date of Burial ..... - il,..{ 19.,5'��
(If body Is to be temporarily held,fill in space later)
Thn Certificate of Death containing the above stated particulars, having been presente to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I ha e accepted the same for registration, have recorded it in my Lo I Record h the above stated Registered
Nu , and orihe b sis t I HEREBY GRANT A PERMIT ,-
to.... . G� 1. •...... . . .
) (A reas)
th • • •••�•.•.•••• .•• to hold temporarily -rd the body.
(uplertaker oriereon having Li charge�of/corpse) (Inter,remove or of rwlse is e of[state how])
Dated .::.. ...lrt 19a�,.. (Signed) O e put y I.oc egistrar�L •"
This Pert6it is sufficient for the Removal (and Interment or Cremation) of a body to any part of the date (aubje,^t 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
Date of . �i t.i e - -1, was ("GG` ",^1,,, 19
(Interment or Cremaihwj
•
•
(Nose of Cemetery, Crematorium, etc.)
Section ?-7 Lot No. 67"-glif Grave Nog
`y e
(Signed) / G G'22-
(Person in charge)
Address 7.1
f ~ L -' (47
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.