Dickinson, Wilber Form VS.(IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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
RAY BROOK STATE -. ..,—,......,:.
Dist. No./(6-9...11.County-—ag it-e-1- e.- (.1.'',.?..=; Village
or City
./// .....\ Rai MOCK'alrivess)
Name of deceased...k:Z.i.k.e.e.R 0114-A TER 41/4 f<:./N:S.CZN Veteran fie
(If veteran, give name of Wax)
4eit Single, married, widowed,
Sex (.... Color, or divorced (write the word) 5 iNa 4 k Date of Death Li e i- /0. 19 Age . r Years , ef Months I:.. Days Birthplace Al4 r.4 4-kali /VS"',
Cause of Death („//Z t:: -1//9- rY- higocww.T;eA.r r•eik(
Certificate was signed by '14...././ei /2/ ..4 .:/-s FA01-1,g ild " M.D.
Address /i"t /Z.54.PRe
Place of Burial (or Removal) ,- e eaN........ e;)4,-.•. 4-"AI,S Ara",
(If body I.to he temporarily held, fill In apaca later)
j .
Cemetery / -,,,,,„ vi A--kt., A.4 Date of Burial ' a '-. V 19
(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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Nu4ses, and on the basis thereof I HEREBY GRANT A PERMIT
to.-LdMoe27.:r-t-d. t.d..- -- 4.-..-7---..,- ic-c°1z ti:Alk- l-‘,4/4kii-4-lik•tev -SA ,t--A Ili, i "4 Ic-c /Vy,
,7 Mips)) j,JAddreas),_
the ' V 4' -,44--. Le'/ e C - ,'''t.to hold temp9a4 and. CA,-7 , .,:c: W the body.
(Undertaker or parson having charge otcorpse) (In or ,or o e a of/ 43.44.
Dated ' ' 1.-' V ((.. 19 -I-2 (Signedha4-4A-4.- • ).. _
Local R
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of a State (subject to local
cemetery or other regulations), artless 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
Date of . was-. -,...— i-D 19 ,`�
_ (In ',sent or Cron
V , 4tk, _ ,,z,,(re,.,.,„,
_,,,,7-L-6.9 .- (.- cd•-•-t '''' '' -
,11(7,.
(Nam of Cemetery, Crematorium etc.)
Section 7 Lot No. / 7� Grave No. / ,
(Signed) 1..-2L� �G`.. �
(Person in charge)
Address ' .fr ,_irrzzi' .. .,xL ,..„
4:464.:
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.