Pederson, Buddy Iona VS.(IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. --Town--- Registered No.—..1__Y.._V....._
air;lldgc
Dist. Nth.6.4/.4.County...lei..� --i..f or City ����
(If eit' give street addre71\1
Name of deceased . . . Veteran
/� I Sin marri :�'!d. ' ed (If veteran. give name of War)
Sex Color t) or ivorced (write ,e word) ' vt-4a?Date of D a y 95,
Age �0 rs .Months .........Days Bi place � . .��G'� �: .�.
Cause of Death ... .. .... �...
Certificate was signed b ...... .... M.D.
Address...,.3../....
Place of Burial for Removal) :r�z - 747
(If body is to bet arily Id in sp a later) ._ a
Cemetery.:- - Date of Burial o`,/"" . ..`' 19'--
(If body is to be temporarily hel , I in space later)
The Certificate of Death ontaining 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 yistered
Nu the basis thereof ERE GRANT A PERMIT : moo'. ( .d
to ) '`sf C - r q ..r.-— .. ' ...........i /....
the �-7^ ..d to hold temporarily nd `y. - '_. LL.'.�aa) the ody.
(undertaker:Toon having charge of rpse) • (Inte rem • orat5'eivci dls,ose of(state howl)
Dated..czs/— / 19.. .. (Signed). C/.�.... .... . ....
-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremati 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.
ENDORSEMM OF SEXIDN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of (, / / was '1:6--v-w.2-,., 19
(In*irmeenntt'or Cremation)
(ha of Cemetery, Crematorium, eto.)
Section Lot No. Grave No.
(Signed) (illJQ
(Person in charge)
Address vr• 0 . ': G c - /.: .,
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SION ABOVE STATE-
MT, 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.