Ryther, Oakley Form vs.Et. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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—_..
2024 Village Marcy
Dist. No.....,.:..:....,County or da or City 2 rcy
(� (It city, give street address)
Name of deceased.../.. .. . . . ... ....IS? e ... Veteran flet.e0
Sin le, married, wi owed, r (If veteran, give name of War)
Sex.% e Color..IA A or divorced (wnte the word) . .. ...... . Date of Death...F.44. ? 19 5
Age 724....Y ars 6 6 Months a.....Days . Bi lace.%kW Ori�%Kr...Shot"
Cause of Death . vY.11... ,J�° I:. 04.e..
Certificate was signed by i.-.E....L.._Z. Gt° i M.D.uV
Address neytea 0 SI-aea li.Q..s ?l rd..f (Yri G„ , P .
Place of Burial (or Removal) r / yam.} E�
(If body is to be to Dorar11yi1�eld, -. in—space later) .� '// // /,G1 /7.5�/ 19
1L y (fla
Cemetery r -- Ti,i.s. :c. Date of Burial.,...
(If body is to be temporarily held, 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 cepted the same for egistration, have recorded it in my Local Record with the abov stated Registered
Nu , and on the basis th �HFREBY GRANT A PERMIT
to I ,, r"..,. tir L..m .1 s.F:�.`- — IN �-.S,t. \\.\.%
y /� (Name) (( (Add as)
the 'Yh% :i .i to hold tempor 'ly and ` . ; . ., the body.
(L(a ker,or person having charge of corpse) ( ter, ove, othe di no a of[state Low])
Dated. ,,� .: ./q6"� 19 (Signed)
De' u t I,oc Begiatrar
fi
This Permit is sufficient for the Removal (and Interment or Cremation) 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INZERMENTS OR CREMATIONS
ARE MADE
1
Date of 'l_Z.0 was .-G :— � 19
(Interment or Cr coati
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) G742 2.- -,
(Person in charge)
Address ,� �. `�jayZA::,
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 ur UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the cords
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNFE(AL DIPECTORS and UNDERTAKERS
violating the law relaidve 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.