Hewitt, Nellie Form va eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Sr 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
No3294county ONEIDA orCity
Dist. City IvIRCy
(If city, give street address)
Name of deceased L 1.1 1 L 0 4.(..4'a.l..l}}�) Veteran /1/o
-p Single, married, widowed, (If veteran, give name of War)
n
Sex:k.12'la.i.f..Color.U„).�.l k..or divorced (wnte the word).. !yj Date of Death..,.�l.4/4aa..4f=.,� 19..rf:
Age • 2 Years. Q Months i ` ...»... D ys Birthplace.. .t.t.G6•xr4.I 4d .i'1..1 j
Cause of Death 'ten: . 6, C.,.,/-_',,� -,k: c1 , ,,,cr >'� 7 le'
Certificate was signed by J �'`! '4. 2 M.D.
Address �`�`�t� /��+ 1`f�,
Place of Buria6,t.Removal) . . ��
(If body is to be tesly held,yiT la space fatty)-,
Cemetery mat .�s. r!„?.... ... Date of Burial 19,�
(If body is to be temporarily held,fill in apace later)
Tim 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 hav accepted the s e for registration, have recorded it in my Local Record with the above stated Registered
�u> er, nth asis thereof I H REBYi�RAN� A PERMIT
to
(Name) (Address)
the �� +- +�✓ to hold temporarily - .d the body.
(Undertake or pe n having ebarge of rpse) (Inter, remove or ogense so of [state how])
Dated 0 19 3 a (Signed) 4i44-4.,—
De put y Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eubjel-t to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
c Q-.o.� cleryrc
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o �7 was ' - //Z 19 //g f
(Interment or•eritimation)'
. ,,.)
r ,
; . ..,---),..... ,..e,..„....- ( -.., ....,..„..„ ----.
4,„/
(Fame of Cemetery, Crematorium, eto.)
• .' .'�-k<"�/C— --<J GZ�-vim�� - ^^ /
Section Lot No. h A Grave No.
(Signed) 'TG->�1�-"� - •-' ✓` ii
(-:es'La.-c.0
(Person in charge)
Address ,'- ( (/(/_ ._,, , ��=-f'
Wit•{--C i-7 _ j_ ?,.
Person in charge moist 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 lords
"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.