Wilson, Thomas NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
jar 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 CE TIFI ATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
i / Town, Vil g Re to No.
. or Cit ..
Dist. N b rJ !1 unty.. .. ...�/�r2<.1�i .. y.. c
�...( . city, st eet ald4ress)
Name of deceased ... . ?:a y�,! 4 `� Veteran !47!J
,\ (If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) L)'-7-` 1' Date of Dea 1.1 c7 19 .2 ...
Age72-11 ears Months Days Birthplace..... .. •
Cause of Death 't.
Certificate was signe by .,A, .. -4,' (sZ-. .. ,n M.D.
Address C/. , _, i.-�.,. - c
Place of Burial ( moval) `/�9
(If bodyis to bet aril held—Or r in-s a a er
Cemetry '.. ...,,(„ . y -- / -Lr,-1, • Date of Burial f/�7 19
(If body is to he temporari held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same App ing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav corded it in my Local Record wit the above stated Reg' tered NumbeG and n the basis thereof I HEREBY GRANT A
PER [IT
to
(Name)
, darC�ds)
the .... . ... to hold temporarily and ::yrL., , the body
(Undertaker or erso ha ing charge of car se) (Inter, remove, or otherwise dispose of (state how))
Dated „/p— 19 .....'�j..1�.... (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a part oT t State (subjecPko local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permi VS No. 62) is required.
FORM 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 ( ��%r-1 /41-c vt- as ,7 719 r/
(Interment or Csatlor)
(Name off Cemetery, Creca,roEi+tm-etc L
izti/L(.-4,47
� �,
Section Lot No.________Grave No. /
(Sign(d)
(yPeerson in Charge)
go
Address Ll "/ ,. �_ ?-)7
Person in charge must return this Permit to the Registrar
of his District within SEVEN (T) 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 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 required, under
penalty, to report violations thereof.