Horton, Betty NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Or This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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.
Tovmt,y_Main gAiZegi ered No. c4.2S93
Dist. No.-.56c)/ County. )C4-4-4-k.) or Ci lee.)er(If city, gi% street ddress)
Name of d eased Veteran ."-2ZC.,)
veteran, give name of War)
Single, married, widowed, Zxjdch4AA_jz,_j
Sex .. .. .. , or divorced (write the word) . Date of Dea9A-,2 /7-02 6 192..5
Age 25.-- s on s ys Birthplace /
( .
Cause of Death
Certificate was signe by M.D.
Address '
Place of Buria Remova ,, ..,
(If body is to te orarily he d, fin trIsspc
Cemetery Date of Burial //— <72,7 1923
(If body is to e temporarily hel , fill in space Carer
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
t i o n,,....b.az e recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERr)
to ........-..e.?..V.1..g4.... .. (ii am. . ..... 14/11.1.err. ......C(.4,,,,g,„ ••• ••••
aats-
/ ress)
the to hold temporarily and the body
( ertaker or pertson having charge of cor-pse) (Inter, remove, or otherwise dispose of (state how))
Dated ,/,/— .;', 7 19 ...V.. (Signed)
.L This Permit is sufficient for the Removal (and Interment or Cremation)of a bo y an7121 o t, t bject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Pe it(VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
LC �•F�f� /biz-z/. /19 7
Date of A- was
(Interment or rratiee-)
(Name of Cemetery, Csu_atyl:u,,,
C
( 7/, C
Section Lot No. ////J/ Grave No.
(Signed) X i? ( lJ
(Person in Charge)
�._
yr-
Address / � l
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 UNDErR-
TAKER MUST SIGN ABOVE STATEMENT, 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 required, under
penalty, to report violations thereof.