Gilbert, Agnes Form VS.ct. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 CERTIFI TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK IN Town Registered No.W.._. ....q
Village , �4
Dist. No... ._.�a.Q .Coon .. � or City
& � (IL city, give street address)
•
Name of deceased rYd�i.�. ,r i
Veteran7 /4/ Single, married, widowed, 4 a?,v' h(t( veteran. 70e of War)
Sex Color. or divorced (wnte the word) Date of Dash/ 4:, 19"• '
Age 7 Yeaj Months pays - ^ Birthplace....,e.V ••• ,.••• •.• •
Cause of Death L.r 7 '!'i-.... . tr` .R ���'lch �a�'4.--e-C.4
Certificate was signed by ;.. c�„ 11- UU M.D
Address . ::` . el l4
Place of Burial (or Removal) .i..1rtl7..4...4,'..� I
(If body is to be temporarily held,fill in space later) .
Cemetery ;it,i-- Cam% vz..'- - Ca.-ptrt.. Date of Burial /a17/5 19...4
(If body is to be temporarily held,fill in space later)
Thn 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 t..e4r. ..sue 4., y ,i:� ..-.ti.f✓..jc#w.. ,,,g...4444, �i, .. ,.
O ( (Address)
the to hold temporarily and the body.
(undertaker or person having charge of corpse) (Inter, remove,or otherwise dispose of[state how))
Dated 1 --...F' 19 (Signed) Registrar -Local
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (subject to local
cemetery or other regulations),unless removal is by common carri r, 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 of was 112--f--c. -2 ? 10 ';
(Intermentt or Cremation)
(Nose of emetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) let ( ttJ
(Person in charge)
Address G r` /` �D d G
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 cords
"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.