Webster, William Perm vs.Si. NEW YORK STATE DEPARTMENT OF HEALTH s.•,..
—..,
OFFICIAL BURIAL (OR REMOVAL) PERMIT
-,,
far This Penult can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration D' trict (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER IGAell OF"..
DEATH. LEGIBLY WRITTEN IN DURABLE BLACK INK. Town . egistered Nd....... ..._ ....._ ....--
)_,./..-
L.9(c-i1 ... „. -,„r_ ).-- ,
Dist. No ..County.-.:1.1,4.14.:4:-.4.,L-44 ,or_ci„, ,i_.-L,...(-,e.--L-A 4,.., e'(;
.1 / . ._eiz. / _ 7 i (If eity,give street a mos) \Y
Name of deceased. I./.‘. z-(-(/t P4J.. .04:19- ( 64/ Veteran
Single, married, widowed, ' i (If veteran. give name of War)
. N /_,/ n ,- r
Se /a.,ii Color‘A‘ or divorced (write the word)11. ,('- )V' ' r 1' Date 0.1Reatti \-., / / r_ 7 lY Ai.'
Age. . ...?:............Years , , Months . Days L
.0.,_ 713ii:thplace.4.,i - fr-.4... ,:'-:: ' .7., ..(-
Cause o Death .. .0`i 'tz 41‘'.e.../L/ (-&l.t.../7.-t,:z..r.-..,,-.-.7.,..4,./„ z er..,-,. , ..,. ..1..)
Certificate was signed kyi-.4.,.--.1.-:.el •i2.4,_.4.'.. .- .‘4f '-/'="`:•.,•‘,. ...?,., ',. - M D
Address. 7j .4I.. .„„( ,
k(
- > ,
Place of Burial (or Removal) , - - c -, C-
(If body is to be temporarily held,till la space later) A 'f. //7
_
Cemetery ,....,-1' ' ,L - r ' Date of Burial (--/ 19
(If body is to be temporarily held,fill in space late
This 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,J-IEREBy GRANT A PERMIT-
tO. ,. ).a.c..4.2/j't-.'"'';::,: -' - il 4-' i ..- 1.i.c,. (....ki‘i .4,: . ..,' /1----',.. -4%„: / (.''I(AP', 8
4,...,, (Name) .
the...,-( '..4- <‘. . 4-14, A-1--- to hold temporarily and ----7 , /,'--- the body.
(Undertaker or person haring charge of,corpse) (Inter,re erwi se diroselof(state howl)
Dated 19..:'..':/.. (Signed)....T... ...i................... ezz.,t.z.).,L.i.L-1,
Local Registrar
7
This ermit is sufficient for the Removal (and Interment or Cremation) of a body to any part 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 required.
CL.--- e.,,,,, ,'"--.
ENDORSEMENT OF SE%TON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERKENTS OR CREMATIONS
ARE MADE
Date of /�i�G r y, ^ w �.�L/��.�19 /f'T s( ,
� n resent Or Cremation) '�
(I
f
..----<Z
(Nam Cemetery, Crematorium, etc.
Section Lot No.(Signed) ':7;;;f1-...- _--C— Grave No.
''' 4iroom is charge) r(` ,
Address , • /f. ,. - <' t r
. Xe.-^6;. 4-'..,"^-?,,7 -.
• Person in charge oust return this Permit t&
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.