Ellsworth, George (2) Form VS.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit zen 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 CERTIF7)/t OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No—
Dist. No. ---(^el/ County ..k) e:::.'.7.-)rar.17:4:71 -. Village— ;- /' ..3 j_
or City ------ce--x-c--,--z. , 4c," .L-' =", '-.,/,/-
. ,
'1 (If city, give street address)
Name of deceased ----'''''-/-----4:'---6-------.7-_,....$2 C±:1141(1"." .". 7.10€ Veteran
1.0_4tingle,inarried, widowed, y. c A (if veteran. give name of War)
Se0. F.gik.Color r divorced (wnte the word) -7 .7,-0-m----2,--4-kze<Date of Death c?--- (- - 7 19. '
Yeal. n Moths , .Day Birthplace
e..-c
Cause of Death
Certificate was signed by _.L-- ' . ---? M.D.
....? .-..?....
Place of of Burial (or Removal) --f---7--1. ee- /9).
(If body is to be temporarily held,MI In*grape later) y ,..., 9, (9'
—t -‘,,
Cemetery '''':- 4--- , - ' 1.-1-1--z--- ,-, Da e of Buria , ;! =: 3 a.—,19. ..,(
(If body is to be temporarily held,till 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, su4on)he basis thereof I,HEREBY GRANT A l'ERMI,. ./ ,/,2/ .7,_
-
to )--/- C.'-- g"- -1 1 .4.-:-.-J...er ,..-- ---''''''----)
--1-7,---7,_,.. ., "7- (------N,‘
the :1,..*,,...., to hold temporarily and . the ody.
(Undertaker or person ha ng charge of corpse) 4 (Inter,reVe,,e4ah,ese 'nose of [state how])
Dated 19 (Signed). .....!::....K.:-.1 .
Local Registrar
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
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of "` .-�� was 2,- 19
(Interment or Cremati )
_12
(Name of Cemetery, Crematorium, etc.)
Section Lot No.— Grave No.
;2
(Sued)
(Vernon in charge)
Address lC77
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 FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.