Butler, Charlotte 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,
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.
4:3
Town, Village Registered No.
Dist. No. :::a4Z,1 County ..1ZST ? 3--4—. or City (0,-C"-'N^ "Q-j-
,( (If city, give street address)
Name of deceased (h i` \ V a- -.\. Veteran 0
(If veteran, give name of War)
Single, married, widowed,
Sex S...cy.Vc.�-Q or divorced (write the word) : AA.?C. Sec, Date of Death (~.. . C> 19 .723...
Age 15.SX Years Mo hs Days Birthplace ' Q4-% `.i <-
Cause of Death —1°.1`..(v� M... !rCdJ�2. `.s:�.C.:'. .
Certificate was signed by c.--'e: M.D.
a C:I^-�tr- s ti,
Address . . ..
Place of Burial (or Removal) . � - ca c- - : '\
(If body is to b tempora{il'y�he d, (i in sp ce ter)
Cemetery �VQ` V°"•`` •i:..s ,,, NM.a._ -.t Date of Burial at.xlek19-7 3
(If body is to he temporarily held, fill i'n space later) )
The CERTIFICATE OF DEATH containing the above stated 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-on
to d-
(Name _ (Aairess) 1
the U/TI ,&I-L,., , to hold temporarily and �W� - the body
(Undertake or person having charge ofc rgse) (I remove, or otherwise dispose of (state how))
Dated
' (Signed) rt 16 e
�ca
This Permit s suf icient for the Removal (and Interment or Cremation)of a body to y part T t i t to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Perm t (VS No. 62) is required.
FOItM 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— IL�. . I- ;vL' ., was :-' 7' 2 19 /7.;
(Interment or Cronweren)
J //
'/(, 7- i'C.. y) c n..-7 L.,_--.._
(Name of Cemetery, C? emia► „tc.)
/--
Section Lot No. Grave No.
(L.,.., r b,,,,...,,...,.... /
‘- ' )1._.
(Signed)' -IL—. ,
(Person in Charge)
Address f` {cl `��y '_� �— - ____
C F LI
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 Regi r
of District in which cemetery is located. .
4
SEXTONS, FUNERAL DIRECTORS and UNDERTAK
violating the law relative to the return of permits are liable
a penalty of NOT LESS THAN FIVE DOLLARS NOR MOR ,
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.