Bristol, Kevin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rip- 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, Village �/�j Regis red No.
Dist. No. 40 / County w G or City ��2=ftS�N� fell
(If city, give street address ' t
Name of deceased I' Veteran
(If veteran, give name of War)
D_ Single, married, widowed, � d
Sex ... �d-�-� or divorced(write the word Date of Death 1`�� •
-' 9 I:4...
Age.......f7 Ye$rs Mons .. Days Birthplace IL
Cause of Death �J --
Certificate was signed b -4-__-- m.17.--=
Address
Place of Burial (or emoval)
(If body is c�.�a to t e d, fill in space .0 er) .—""'
Cemetery f............_... fs [•... .. ' � � Date of Burial Zia 2 r 1924
(If body is to he temper tly held, fill in space . er)
The CERTIFICATE OF DEATH containing the above stat-d particulars, having been presented to me, after careful examination,the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record with he above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERAti
thedaame) 4ces t
elA to hold temporarily and the body
(Unde r or erson having charge of csrpse) (Inter, remo .r otherwise dispose of (store how))
Dated ... vi-7 19....... i r
(Signed) _, - ,• - . r i
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any par - t el'. 1.t f -. D"al cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS .. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
,
Date of was !1�.. ...1i.-1 ,e,19 7-id
(Intermit or Cremati.n)
;
,1)4 . LAA ( L�
(Name of Ceme ry, Crematorium, etc.) G`
r �y
Section • r " Lot No. oC' Grave No. 4 .
(Signed)
( erson in Charge))S-6-A-.0
Address 3 J a161) cJL !V, r,
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 F NERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVESTATEMENT, write across the
face of the Permit the ds "No person in charge, d
FILE PERMIT MMTNIN.TiREE (3) DAYS with the Reg
of District in which cemeery is located.
4
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE S
violating the law relative to the return of permits are liable
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. Th
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.