Carlson, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. t 7
CC 1 Town, Villa . R sterrd No. . l f
Dist. No.J6-U( County :V G _ City �� '� `'� T . .f'�L? �
(If city, eve street address)
Name of deceased (/..0 .... .... a:.»ct./ ......t�r.(C.:. ru".Veteran 7.
— 61.
' (If veteran, give name of War)
•
Single, marred, widowed, S n�
Sex /// (.4/(�:� or divorced (write the word :k1.ye& Date of Death . 4,%'` 19
Age 7/ Years2 on s ` Days Birthplace. 2�` 'f�C..,- '
Cause of Death \ �,�'.. .• ak.,�. / is..
Certificate was signed by ,�... M.D.. ... u
Address P-4.i: ... ,- . ...0 e ' ,
Place of Buri (or Remove .c�- "�,,..c..
(If body is to b t °rattly e d i space later)
Cemetery - Date of Burial14 19,�
(If body is to a temporarily held fil in spacel er)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same 4ppearing to be COMPLETE, CORRECT, A D SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, h ve recorded it in my Local Record with he above stated Registered Nu ber, and on the ba 's thereof I HEREBY GRANT A
PER 1 j
to .�.... / a ress
(Name)
the !' to hold temporarily and(4),...‘i tv,
`�,' the body
(Under a er or rson aving charge of corpse) (ICE r otherwise dispose of (state how))
Dated — /./ 19/.2..*3 (Signed) 401....../. ..t,I,r4,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to ny 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.
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 of 'nv1 was / 19 7?
(Interment or Cremat'on)
l,,.1�i �S✓YI14G.4.i,(Name of(qi
etery, Crematorium, etc.1
(9
Section =•Arra g Lot No. '� — Grave No. b
4. S
(Signed) Person
-tiLi-t.
(Person in Charge)
Address J /JA�-r va�l� .� a JL '� /fi>> /'
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," 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.