Welch, Adaline Form VS.Si. NEW YORK STATE DEPARTMENT OF HEALTH
. OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr Tile Peru*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 CERTIFICATE OF
DOOM, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town . Reg
istered No.�9
Dist. No..1 .G/..Coylnty ._.. /...t: a. n.. or City
/ (If city,give street address)
Name of deceased L I c- ..%:`.i.. /` Veteran --Q
Single, married, witj•Wed, (If veteran, give name of We')
Sex �/ Color I.,t� or divorced (wnte jhh word�),;Z .d..7�. ' Date of De ie/2 d 195 Z.
Age 'J ...Years.... Months................_...Day' • " �,Birthplace .. . .�:.�:..r
/'� ,7
Cause of Death (,,..2.,Z. .C. ,z ..�1. ••:j -12, .� •
Certificate was signed by r�� �
. .. � � �.... .. M.D.
Address .c..�. ' x
Place of Burial (or RemovalY :;/ ,. s -C. '..,.... ....
(If body bi to be temp arily/�'l ; space later) '
Cemetery ... . ...�G;uri Date o Burial /d / a- 19.:,i:j
(If body is to be temporarily h d,fill in space later)
The Certificate of Deathcontaining 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 acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, o , e basis th I HEREB GRANT A PERMIT .
to .:ram.... .....
(N ` (Address)
the -� ,. ' .... j�-�i� to hold tempo ly nd the body.
(IIndertake or pe n having charge of corpse) • • (Inter, o o ■nose of[state bow))
Dated Z. < 19.d.,t'. (Signed) t...�
.. . .......... . ..
Lee Registrar
This Permit is sufficient for the Removal (and Interment or Crematio 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.
N•tiL
ENDORS•E OF SE;X1UN OR PERSON IN CHARGE OF
• PREMI SES•CIN WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of • 2 Ohl was " 19 s
• (Interment or Cremation)'
• y
,
(Name of metery, Crematoria etc.)
Section . Lot No. o`+' Grave No. (o
'‘� �.it
l I)Qe, •
,(Signed) V -�W •
(Pepen in charge)
•
Address - 1�E G. 0 ,,qq , ‘-1
Person in charge utist return this Permit to
the Registrar.of his District within SEVEN (7) DAYS
from,above..date. .. j zoo pexon is in charge, the__- -_. _,-,,._....•__-
FUNERAL DIRECTOR or UNDERTAKER MUSTEIGN 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 OFmNSE.
The law will be enforced. Ldcal Registrars are re- `
quired, under penalty, to resort violations thereof.
i