Thorton, Arthur NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. —
Town, Village . Re st/ere No. ,
3t
Dist. No. •- ` ` County..A.:G-• (�---- or City
_ .c z........ra'
(If city, #ive street address)
CALL_` `
Name of deceased L /� Y �.. .t4�� c Lr�.� Veteran +
(If veteran, give name of War)
Single, married, widowed, -7") rf
Sex /'i/F, �� or divorced (write the word) w '6. K.:. .mate of Death .. /..G.'.4` 19 -f�'
Age C::.I Years Months - Days Birthplace
Cause of Death ,'7` z- - i:.Z ...Gr7.1,...,.; ;,
�`�
Certificate was,signed by �,.r � "' M.D.
Address /'' C ' .ti ' 6- ... "f 1. f r .
Place of Burial (or Removal) Lr-t � �!
(If body is to be temporarily held, fill in space later) •
Cemetery Aa `'-� Date of Burial /)��-L' / `/ 19.
(If body is to he temporarily held,`fill in space later)
The CERTIFICATE OF DEATH containing the above stat d 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-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT, i , /_. / ,
to L t- ,.-1 -'lit. /'G k ' l�.Lw / 1. = '' .y , (:,t ,4 .c-%+�, NA 1./ •V
2~� e) -�-__ iovadress)
the "(4-1- ',4::--J to hold temporarily and e'I the body
(Undertaker or person having charge of cor sew) (Inter, re , or oth7 se . os state how))
Dated ::,' `''c: /'.-G�.4- 19 /._i (Signed)
ca
rar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part f the Steate (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (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
Date ofC� /` `` f /f`�'4 J was l"t(` 19 ='�
(Interment or Ptinnl
a
l � .1Z. l C C G S
(Name of Cemetery, Crefla ,_etc.)
Section Lot No. / .) Grave No. 2
/
(Signed)"
(Person in Charge)
Address
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge, d
FILE PERMIT WITHIN THREE (3) DAYS with the Regi ar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERT S
violating the law relative to the return of permits are lia to
a penalty of NOT LESS THAN FIVE DOLLARS NOR E
THAN FIFTY DOLLARS FOR THE FIRST OFFENS . he
law will be enforced. Local Registrars are required, tieder
penalty, to report violations thereof.