Miller, Edward Form VS.111. 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered
:
Dist. No...i-.0 41/ -Village County 4"1-/ 1-:**4-7'..--"---- ----
(If city, ve street address)
Name of deceased (‘---- t..../L'' ------..--,P ---$... "1;,. . --C., j--'-.-- Veteran
(If veteran. give name of War)
."-/;/ li Single, marrlecjf. --Widowed, /... I' '
Sex'. Color ------" or divorced nte the word) --v----(--/---7=- -- Date of Death 'fr- .e.A.Tr.ir..
Ag . ..tC(WYears
4
Months ...., .Days •i Birthplace..-"7t--4,-.-*-)
el. ' /'
Caul" Death „:" ..1:-.-:-.,--.,„- :..v......4-.. 44---.....r.t..........-.1-..4'4.4.1-0.....2t,..,
Certificate was signed by -1— 11".4--4----- ---.... ../..,.-0 P.,./.-n-C::(4-x-s-,--
Address V '-- ,-- ,
- ..........y --,04.----„,---
vt• • ,
Place of Burial (or Removal) ‘-.--...4.:. . 441 .•*1 4'1-
, t,
(If body Is to be temporarily lieldfill in space later) (./ .. " , i .— _
Cemetery.-.....V.--1--• '----' ''''4"--1 `-t-71•-411•41-'7, ..._ -;.:-.--.g' Date ofIftiiial -\\/....:24 - -,;--- 19.f.1...7
(If body Is to be temporarily beld,fill in space later) --- -
The 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
Numbey, and on the basis thereof I HEREBY GRANT A PERMIT(
to..24-' .c::::,-,1-1s7.-71a.--L. ..-&"--- -24.:,-,:ke.t..;,-;
-- - ji::--1:-1---2.---u . --, , ,,,,2 -
/ &'..(2ktldress)
to hold tempo 'ly d ,..1.- ---",----c4,........, he body.
(bloylertaker or person baring_charge tif....cfpne) . (Inter,r ore moose of[state howi)
Dated.......... .--.„ . .: •'' .19.....t ./ (Signed)
i Local Registrar
This Permit is Sufficient for the Removal (and Interment or Crematio of a body to any pout 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
eht13-
Date of was 19 45 9
( te men t or Cremation)
(Name of metery, Crematorium, etc.)
fJ'L1.)
Section ` Lot No. Grave No.
(Signed) al&
(Parse in charge)
Address C . " L
• c •-a---e---49
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 SIGN 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 FIE(ST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.