Davis, Myrtle Form I&IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir 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—Z. ea
Village
Dist. No 6 ° County..-7/ .4-.V-rerz-- or City
—
Name of deceased d . (If city,give street address)
Veteran 'z1,4
ied, widowed, (If veteran, give n a of War)
Sex V Color. Single, marr
0- or divorced (write the word).,&./44/.. . .... .......Date of Death 19`S-1
Age 4" 9 Ye rs Months Da s Birthplace -24.1...ts/-
Cause of Death..... ... . . . .........
Certificate was signe y rej M.D.
Address c.. ..,-2. - 8,4,4,7( )2 y4,
Place of Burial (or Removal)
(If body Is to be tepe,ftylly hW.,./111 lipkaie later)Cemetery .... ....... .,. . . ....
1:(.4e.Zari.- ' ,e." ..r.K.--% Date of Burial s5"--1 // 19.67
y
(If body is to be temporarily held,Ill 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
Number, on e basisp.erkooM_EREBY GRANT A PERMIT c_ .../.4...., 7
to
the . fr4 (r4Treates(--i'- to hold tempojarily and. L.YZG----- (Address)
the body.
(Undertaker
s.ojz having charge of corpse) 2 (Inter,re raj/here/A.77m 6 of(state how])
Dated sreo /l 19......57,
Local 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.
j
c ' .
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREATIONS
ARE MADE
i / was
Date of /Ll/ /7 195�
7
(Interment or Cremation) J
4 2/11/' ' 2.<-Z-(6-; ' - - ''4- C--- ‘-:;:/e-n-(7 .'- ,
.r Name of Cemetery, Crematorium, etc.)
Section r' Lot No. Grave No.
((Signed) 47,-
.1 -/.1—-tip P_�'(�/ 7
/77
(Person in charge)
Address / G-K : 7
,.......A0,04...— --1:4 ----
Person in charge must return this Permit td✓
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 FIRST OF'FtNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.