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Perkins, Earl 12-)'-' / � (Few�� i. NEW YORK STATE DEPARTMENT OF HEALTH ` 7 4 OFFICIAL BURIAL (OR REMOVAL) PERMIT R: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 FLUNG and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No.�n2..a3. ......... �i Village Dist. No '-5C� .ZCounty.. ..,11, 4 :Y.Y. i..- or City --/ (If city,give street address) Name of deceased EC--1 .1�,:1...�a`I��:i�jj ✓• .a/� ,r.. Veteran 'G.-Z'— Single, married;%idowed, I c (If ve ran. give name of War) Sex / I Color /./.' or divorced (wnte the word). . .. .. . Date of Death ,at4�'u- .?. • 19 � Age 7 a Years Months Days Birthplace.... Cause of Death '.. .. -z..... .. v -j••• Certificate was signed by SJ .. .., M.D. Address Place of Burial (or Removal) G-..e..,a..c,fY.r..... ©7y{,c./.. ..m.•••• ... (If body is to be tempor ly held,fill in sp ater) / t Cemetery .,.e..-r�/.:� . �.� 1 Date of Burial ‘ / ?-.S 190:7./ (If body is to be temporarily held, 1 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 on the basis t I HERENT A PERMIT to ...... ? .4 .... ................. .._... .14a. ,c..........c :I-7....21. „ the to hold temporarily and � (Address) - y. (Undertaker or pe}+�n having charge of corpse) (Inter,re y '� . the hod,or otberylse s p of[state h w]) Dated fa...f...2 19 -7' (Signed) .t..;ak "a -te- C Local R This Permit is sufficient for 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 common carrier,in which case a Transit Permit (VS No. 62) is required. ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTIBMEDiTS OR CREMATIONS ARE MADE • ,1i1�- �19 l�Date o / iiL C-�1�7�.- , was .. (Interment or .Creeart71Sb) .. 0 prJ.( Iles . j amb of emetery, Crematorium, etc.) i ) Section Lot No. a Grave No. L; (Signed) /',Cy�AC,-� '[ �'_C''1L � (Person in charge) Address 6i//1 ,Zt2 �%n :-/-44/ 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.