Myott, Laurie l' rm VS.al. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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. Towle, Registered No. .._...._....._._
Village v
Dist. No.l•1?.\ unty �`' ' .:N4.` or City .\.t° �.
• (If city, give sir t address)
Name of deceased. .. .. . ,J ? . , ...• -. ..- . 0-4. . veteran
. / Single, married, widowed, (If veteran, give name of Wer)--�
Sex' Color 4� `or divorced (write a word)... • Date D th L••." 1�
Age / ars N., ...Months.•.. .......Days Birthp `
Cause of Death- •. ... � ,•. .•. • z........ •• .. 5.1'._..,
`-Certfrcate W igne by • `' . a. s n ICJ M.D.
. .
Place of Burial (or Removal)
(If body is to temporarily �d,�4U Ine later)
Cemetery. cr ' �.•': .. .>.. ... .. .. Date of Buri t..s. ' /
(If body Ii to be temporarily held, fill In pace later)
Thn Certificate of Death containing the above stated particulars, having been presented to rne, 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 Roistered
-..Nu on the basis th I HEREBY GRANT A P IT .• �
to • - •-� ...
t (Name) ..- (Address)
+ t,� r the bo
the.... to hold t 4ri,y and -i y-
nd ker or person having charge osor ) (Inter;remov a of Wats w
• 2( 19.• •. (Signe
1 Local Registrar
This ' ..'t is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (.abject to local
cemetery or •er 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 was ! 0 197
(Interment-es-Csa
(NEW of Ceme ery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 11.0Q-'(.11iCtt...,1----12
(Person in charge)
Address /CD' Q . (T 6
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-
VENT, 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.