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Varney, Grace Form VS.01 NEW YORK STATE DEPARTMENT OF HEALTH ;' r OFFICIAL BURIAL (OR REMOVAL) PERMIT tr 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 Town Registered No._ Village Dist. NoI.1: ,Q.f...Coun ....lf.��"(1..LTrt`1c'e-Px ... or City /�j (If city, B ve street Name deceased 'I/ 'v Veteran Ingle, married, wi wed, (11 veteran, ive name of War) — Sex Color .or divorced (write the word),. .. Date of eatl_i . D..l.Q..,?..19 Age ,7...1 Years. Months .Days Birthplac es . ... ... Cause of Death ,.r` . s5t. ii- 4, - /y . ... . . Certificate was signed y... .. . .... .:. .. . .. . M.D. Address Place of Burial (or Removal)........ .. ( . (If body is to be a y held, sp ce 1 r) Cemetery �#1,--x- ..r l , Date of Burial...., ..2.. .../..i..7 19 (If body is to be temporarily held,fill in spat later Thft 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 cepted the same for registrati , have recorded it in my Local Record with the above stated Registered Nu t on s' thereof I REBY GRANT A PERMIT the to hold temporarily and ddress) • the body. (Under ker or person having charge of corpse) (Int " ove, beryl nose ose of [e how]) Dated 19 (Signed) l r. R This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (*abject 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 INTERMENTS OR CREMATIONS ARE MADE L-t2e--4i-_ Date of was .�G � 19 7 (Interment or Cremation) -x,i4 , (Name of Cemetery, Crematorium, etc.) Section Lot No. x Grave No (Signed) ��jJ --X; (Person in charge) t(01' Address Ilkf 4t- 1 Person in charge crust 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.