Willett, Charles Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ger 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- Registp* No.
Li -
Dist No'7 ti v44/Co ; - o li—ee,e.,‘ -`-.7zrz.efee'7
,....D . „ ....,,,,,,.._."- (If city, give street address)
Name of deceased.... .. .... rsp. . 1,001‘,eZAA ee Veteran
(If eran. give name of Was)
Single, married, widowed,
Sex....(I) .Color or divorced (write the word) ... . . ... . .Date of ea • .Dts..7. 5),,,..
. '''P''''i, .
Age IN.,, Yearse Moirths Days Birthplace. .. .. .
Cause of Death
t••••--
Certificate wasf•Stil' by .. M.D.
Address....4.--..A..:
Place of Bur*ictirr R v J,,4-,.c.t.... .....",„1,4dir CT-ArtrelAVA • ''''. ,,„
(If body is to b r y II n s ce late . l ...c. z &"--
.,
Cemetery,' • Date of Burial 19
19 c-
(It body la to be temporarily h )1I,fill in space later) 1
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 accepted the ImP,for registration, have recorded it in my Local Record with the above stated Registered
N , and on th 13 sia j•jkieof I 131" GRA (Address) pe,NT A PERMIT , , (":47.7zege,
ha
t--(Naine)
die to hold ternpor ril n ,i,' .. the body.
, ker of• rson27 than:57pm)Dated (Signed) (Inter,remove,orrrise disnome of(a o ]
..(r.,k • 19. J
Local Registrar -
This Vermit is sufficient for the Removal (and Interment or Cremation) of a o any pert of the State (veihject to local
cemetery or other regulations),unless removal is by common carrier, in which case a ansit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date oft-rv-z= was ('e, G� 19
(Interment or Cresol(
(Name Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
I p(signed) )
(person in charge)
Address v . 1 6G c C e , , , `y
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.