Barber, Ambrose 5 _____
Iona oa 6L NEW YORK STATE DEPARTMENT OF HEALTH -ff')` " "p 7
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itir 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. �--' Registered No. .._.._._........_
Dist. No r lr
County.� :5�:'��! or City �_ ..
t (If city, Bice street addres
Name of deceased.. .... ..... 4... Veteran < i//�..
Siugli, fisarsed widowed t (If veteran,
give name of war) y
Se o, Co .oc�ivereed (wnte the word)k" Date of Death �� � 19 .,/
Age tr I Years onths "r'' Days Birthplace beer,4
Cause of Death : -. �
Certificate was signed by ' /-:Ite 4f! • - M.D.
.1r
Address.
Place of Burial (or Removal) —C h.,C i_c,s 77:— ..... - \ . / ZI= 4
(If body is to be temporarily held,fill In space later)
Cemetery �" '"'--- Date of Burial...a • L. C 19..5/
(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 appearin: to be COMPLETE, CORRECT, AND SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the gam. or registration, have recorded it in my Local Record with the above stated Registered
N , and on basl t•..7•f REBY G NT A PERMIT am_
Q
4J,t' .. ) ,ddreas)
the to hold tenor and • he body.
Undertaker or perao ha n charge . rpse) (In r, remov . se n e of to how )
Date .57�.... 19f�t ... (Signed) <
Local Registrar
This Permit is sufficient or the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by comm74 rr r, ' which c e a T sit Permit (VS.No. 62) is required.
ENDORSEMENT OF SEXTON OR PER RA IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o /7GLeirt..,-/ was --2-(1-5 19 L /
(Interment orb+ en)
,�) `/. CL / .•
(Name of Cemetery, Crematorium,G J
qtc.)
Section Lot No. 7 7'V Grave N .
•
(Signed) ��La- -� .-e-Gr? (
(person in ckarge)
Address !� / /�L` � -' N.-de,,...77.-
1,I i. i
Person in charge mist return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER S« SIGN ABOVE STATE-
SENT, 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 .o 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.
1