Vail, Mary form V8.SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 CERPEIPATF OF
DEATH. LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._..._..r__...."_.__ _
Village
Dist. No...41.02 County....acass... or City Tro.3ry..4Y.Z.
� (If city, give street address)
Name of deceased C��14' t ° -.< Veteran
7 Si le, married, widowed, (If veteran. give name of War)
Sex /r Color 2t o ivorced (write the word)'1 -4- ti'— Date of D,e,�th Oct '% 19...59.
Age 1 }-' Ye rs. Months.... Days Birthplace '!�."<7 r c
Cause of Death .-�, .,- �. . .......r.,c.r.7. x..:c::a :s.. s
Certificate was signed by C s.i..., - r �-� r M.D.
Address A..s.7' c..: �4 s'i ,� - -:�.`• �_:,� , 1 .
Place of Burial (or Removal) ... (i...4„. .-...t.:r:4.. ,.- -J .1. k. & .£.-: y ell-:
(If body Is to po }y held, in bpace later) / f
Cemete� t.k! t.� :u..i. Date of Burial Oct, 19,..59•
(If body is o be temporaril held,fill in space later)
Thi Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRE , AND SATISFACTORY AS REQUIRED BY LAW,
I have;accepted the same for re .stration, hay record t in my Local cord with the ♦e stated Registered
N , an the basis
er�HEREBII GRANT PERMIT / ;_----_ .�J /
to` �ti,...ds
-? vtr, ' / C"c-4.2 ,Z"fir C c 2�. ‘-e," - C ��{ /,� �' txamej (<."---,1
(address)the:.. % .t.. #iJlde.Y:ts�J.cfx to hold tempora ' y nd a,, the bidy.
(Undertaker or person haying charge of corpse) (Inter,remo a moose o�(state bow]) / , J
Dated ;)ct.....2.9 19...5.9. (Signed).... . � AK istraz.... .a�Local •"f
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was Oa 3 I 19
(Interment 0--norj 4 ,• J
S
(fame of ete , Crematorium, etc.)
411
Section Lot No. . Grave No.
(Signed) U'i2.ti�• L�M J� .�
(Person in charge)
Address ✓ 5-- &Ad
r .
Person in charge t return this Permit to
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-
MEET, 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 re—
quired, under penalty, to report violations thereof.