Ainsworth, Grace Form VS.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can be signed only by tie Local Registrar (Deputy or suhregistrar) 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 O
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town `"
Registered No. .._........_
Yiltage
Dist. No.S�s f County... /� /%' � Ci ..
or ty � yl�
(If city, give str t address)
/
Name of deceased - GZ-- `-' , Veteran
/, . - Single, married, widowed, (� veteran, Give name of War)
Sex r (eEEolor. ..� l..or divorced (write the word) . ...... .... Date of Death. .11v 1 • `7,, 19-' .2
Age 6'.6 Years Months} ...Day T"Birthplace 7�`z-0 1 `7;)•••t•7
Cause of Death.....C-t-'� . '.z /? ,. ..
Certificate was signed by , 4-14 ... 0 M.D.
Addresrt I S.t.., ,. , eg..l. .- `. .fit `- .- ,
Place of Burial (or Removal) rr -Z :-'-- -t-"/
(If body le to be temporarily held,ill ins a later)
Cemetery 42G' r:�rr.�G�rrrFG.. !ate of Burial /...//.....C� 19.. 7
(If body is to be temporarily held,ill in a ace later) 1
The Certificate of Death containing the above stated parties, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hay, accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num , and on e basis thereof I ,HEREBY GRANT A PERMIT (� ,
) 1 s)
the..; to ho d temporarii -and .--a-..L, the body.
(, dertaker or Derso aving charge ef-cor se) (Inter, remove,or othe Monona of(state how])
Dated.... :{i-� 19....)..7 (Signed) ._ ,,.. .� -,G.�- :G.
ze . '
Local Registrar
" Permit is sufficient for the Removal (and Interment or Cremation) of a y o any part of the Slate (subject 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
PREMTSES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
c
Date -4--� �'+was � . ;27 19 0--7
(Interment or )
(Name of Cemetery, Crematorium, etc.)
Sectiont / Lot No. 7 75Grave No.
(Signed) r J4l0,,/e_Y,L---r.l C;00"'j-L, %((J ,
(Perin charge)(Pe on
Adddress'./C i /-,r(yZot.
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.