Wood, Lewis Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) of tie Primary Registration District (Tows,
Village, or City) in which the death occurred after the FILING cad acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No. .._...._........_
Village -?
Dist. No County.--...................:.t: ,l:L., or City r' �,:."--"
(If elty, Qtre street address)
Name of deceased /�� Veteran -ti
/ Single, married, widowed, �7, (If veteran, give name of War)
Sex Color.... or divorced (write the word) t? Date of De th 19
Months
Age - Years Days Birthplace ..�..� ..9,7.`
Cause of Death 1- �a ,,/'.a .. . .� ....‘...
Certificate was signed by . .l.�rC�s.�..fr �l'1 c c4.....- .e M.D.
Address - ... 4. "1' q,.....
Place of Burial (or Removal) , r',? . . f: 7 L
... , .�...,� .1.
(If body la to be temporarily held,fill is space taper)
Cemetery .:-lc 6 Date of Burial 1 ,..h' 19
(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 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 Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to . a.,.'Kl... - t
(Pismo) (Address)
the rl•6• it.:. to hold temporarily and..,.:: .. the body.
°Undertaker or person hating charge of corpse) r, emoveio the ee •of(s 'how))
Dated ,1. 7/ '- 19..._,:. (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pet of tie Nato (wijeet to local
cernoltery or other regulations), unless removal is by common currier, in which case a Transit Permit (VS No, 62) is required.
ENDORSMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date was 1X252,77
(Inter.ent or
c1
(Name/ Cene ery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) �Ce
(Person in charge)
Address ZILVV.,/,,PA24-
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.