Kilpatrick, Anne Form VS.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ft This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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.-.-..-.............._
3301 ONONDAGA Village SYRACUSE
Dist. No County or City
(If city, give str address)
Name of deceased(1) irt2� Veteran•
`� yr-
y1,j Single, married, widowed, (if ♦eleran, give name of Was)
Sex Color or divorced (wnte the word) Date of ea �j, �^ 7 19. 1
Age....51 Y rs -` onths - ..Days Birthplace r oc° (//
Cause of Death
Certificate was signed by.. �, M.D.
Address 1a5 ',12� ... .
Place of Burial (or Removal) .. .. '-(2-1-ed)
(If body is to be mDorarilv,held,fill i�,,space 1 ter — _
Cemetery '� 'Z ( ��ti�. Date of Burial 7 19 S
(If body is to be temporarily held,fill in space later)
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 'have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num , n the has' th I EBY GRANT A PERMIT
toil ')? .
(Name) ✓' ("Address)the ' to hold temporarily/annd� remove, the body.
(Undertaker or rson having charge corpse) ( gn ) (Int"w or otherwise dimose of[state how))
Dated 'j- _ 19...5.E (Signed) A c— DEPUTY Weal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (*abject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date `/j1.�L s=-t-sLc-t // 'was � i ? 199 '7
(Interne t or )
(.."
. i��<,E /C t-to- :.40.�r..cr
(Name of Cemetery, Crematorium, etc.
Section 2.- Lot No. / ,- d Grave No.
i
(Signed) ��`J[ � - - /�L--C�ts.V ' / s
(Person in charge)
Address at L'L / ' L o f� '
...-ez,60 ' 4-e-e€Person in charge must return tHA Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no perscn 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.