Haines, Adda Form vs.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
f This Permit can Iva 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-4.....7...2:�...__
ONEIDA Village MARCY
Dist. No.32.2!±-...County or City
(If city,give street address)
Name of deceased... w.6i.i. °
� Veteran ''- F
Single, married, widowed, (If vetera ,stye a War) /2"
Sex �• Color. .........or divorced (wnte the word) Date o f, Death .... `:c,Y .! �' >....19 `1-5
/! jj .
Age 7G Years ff Months '7 Days J Birthplace.}4.,...r"� a .4 ' ' 4 3 e J17�!q
Cause of Death ��e,aCA. 4'i/
4
Certificate was signed by x: ;.‹, , Z..,adtret;..'h:... M.D.
Address. 1'1 1 F;t. ., i..., -
Place of Burial (or Removal) Gr ... .
(If body is to brympororily held,n}�in r) / /c
Cemetery . ..a..:il.i.rx-'' 1 �? e Date of Burial 4(11- L ( 7 19
(If body is to be temporarily held,fill in spa a later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, th same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have pted the or °stration, have recorded it in my Loca Record with a above,.stat ' tered
Num , and on b S. HEREBY GRANT A PERMI ....
to
(Name) ddress)
the.. to hold temporarily d ... the body.
(to or}person having eharg ) (Inter,remove,or oth rwi os�to how))
Dated... , .,‘ 19„ (Signed) r{
Deput — rai Re
This Permit is sufficient for the Removal (and Interment or Cremation) of a bodyoc
to any part of the State (*abject to local
cemetery or other regulations),unless removal is by common currier, 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
271--/
Date was , t' 7/ 19✓J'
(Interment or C��
(Name of Cemetery, Crematorium, etc.Y
Section C/' _Lot No.�13 Grave No.
r"
(Signed)
(Person in charge)
Address
f _
Person in charge Heist return this it 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.