Holmes, William form•8.11 NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District.(Town,
Villap. or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFIC#Th OF
DEATH, LEGIBLY WRIT/EN IN DURABLE BLACK INK. Town Regist No.r.._..__...... . .._
Dist. No.:S. ' I -`�;;�z VC f
�:�..�....County.. �"{''.� or City .�'.�— ti:T:,� .��::�� e-�-z �//////�-
• ..... ) (If city, give street addre
Name of deceased :t:,t1 1. )/.Z:�../ =' Veteran 7.
• „ Single, married, widowed, (If veteran, g e name of War
g iv )s
Sex.V.1L(- '—• Color.dt-Cs:04..or divorced (write the word).....: .6,,;z .{.Z.r Date of Death. V 1:.4,r . ..1 19 7
Age . :A Years Mpn s Da s p I irthplace:e✓:644:a....ertl' ... ::
Cause of Death .t4.rrk X eca ?' : .. -e4- :, .4t4.�.�� • tr P44� zr,• -& `. �y 1 .`r z u7za � c �'% tit
Certificate wasusigned by.; �� �c s 6 -j[ z s.,,F� � C- c c�t.�
'«,�,,�}}r r.".�2.-_ �'. -0`1...q.. .C',�r..f•.-.p: a.e.: .- M.D.
Address.' :�.:.::,,{.. w?�`P... i..G.rtis `3.74d4.r
'Y
Place of Burial (or Removal) )`-d F Z,:.u.k4.4:4. )
(If body Is to be temporarilybeld,fill in space later)
'2.
Cemetery �-� r�e.�[G:�r:L.:�:%,?.:'. :� Date of Burial...::.li�:.�'.h�.�„ � 19�-> .�
(IL body is to be temporarily held,All In space later) /
The Certificate of Death containing the above sated 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
Num er, and on the basin-thereof I HEREBY GRANT A PERMIT
to Circe'f �, /�l�S�t )i
1..:..., .}r.::,�r:k:Cr�' .;:�1.�:fL�fF4�,f,..�l."'t' . .1la
��'.�'r..... `.1r,6(
.---9 (Name) l
the r' !. `4 4: r to hold temporarily and .:. z..,:Z�:; the body.
(Undertaker or person baving charge(.rf..� of corpse) L.,-7(Inter,remove,or otberwis-g nose of[state bow])
Datedf...Y.L ..1 v^ 19 .. (Signed) ' C:. cii-t ....; ' ..1...�.-4�!Tr.4.. t7
��� Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bodiy/to any pert of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is require..
ENDORSEMENT OF SEXTON OR P SON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CMIATIONS
ARE MADE
Date o ; LL=� - ` < ��G! 19� - .-
(Interment or restating) �—
' ,76, '*--• 404..e..,..- C.'...-..'°-'6.^-2-7"?...e.....--`11,9-,--*7 -
Marne of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 73., 6;
(P� 1 C' '�.
erson in charge).'�
f
Address o 4
C,..2 ,, 1> +�..."�;,.,,,/,' ,
Pe�'~ in t returx his Perthit-i
the Registrar of his District within SEVEN (7) DAYS
fran 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 -. „, .R44
(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.