Sovereign, Ernest Form VS.6L 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,
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. No County "ssex or City Ticonderoga, New York
(If city, give street address)
Name of deceased Ernest; S Q V e r e A,gll Veteran .,.....N.a
(►f veteran, give name of War)
Single, married, widowed,
Sex Color " 1 1 t e or divorced (wnte the word) I`1a r r i -- Date of Death Mar I Li. 19
Age Years Months Days Birthplace C,iad .a.
Cause of Death Carcinoma Larynx
Certificate was signed by D r. J . P. J . C;un.n i ns M.D.
Address Ticonderoga, New York
Place of Burial (or Removal) � Ile ens bury, New York
(If body 1s to be temporarily held,MI in space later)
Cemetery Pine `fie Date of Burial Ear 1.7 19
(If body is to be temporarily held,fill in space later)
Thy 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to irby D. Wilcox co:lderQA ,,, �I.e�a..... .k.
e Wawa) (, dares.)
the '�p,d r 1 t,T: .1 T' to hold tempora '1 ..and .Add the body.
(Undertaker or person haring charge of.corpse) (I to , ore,or otherwise(Livorno of [state how])
Dated Mar 14 19 (Signed);. . . . r'r�`'
Local It
This Permit is sufficient for the Removal (and Interment or Cremation) o �� fy to any p of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Per t (VS No. 62) is required.
ENDORSEMENT OF SEXTON OIL PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of / L 2 (7 19 ,o
(Interaent o /—►ren), ...--:7.1-,-e; /f---elf, -!; //('
`
j/2
(Kane of Cemetery, Crematorium, etc.)
Section Lot No.�,� Grave No. /
(Signed) ti ` r
rson in charge)
Address 7L�
G�LI6e‘- —,,\‹; __. ,t./64--
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.