Tucker, Charles s
NEW YORK STATE bEPARTMENT OF HEALTH
OFFICIAL BURIAL:(OR REMOVAL) PERMIT
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air- This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, or City) in which the death occurred after the FILING *d acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. I
w„ 'Town, Village Registered No. .
Dist. No... .��.1 County..c...?,. .C,l, 7\5 .. • or City C `G\.3 �'-ac.-�r`-D
(If city, give street address)
Name of deceased C' -\ ,, "'�1 � Veteran �� �—
(If veteran, give name of War)
Single, married, widowed, p
Sex \N.c^ or divorced (write the word) -'`NLAGX.i,JY.1....Date of Death ' . -�� 4 19 .1
Age -1 Years Months Days Birthplace w.+ Q �CS -
Cause of Death GG..a 03'c, ..Nt- 4 ...Y .. ... ' .
Certificate was signed by 2 tJ I' M.D.
f
Address �.:7.S.:ti 5-C" —
Place of Burial (or Removal) .... . . a, . .f
(If body is to be tem ily held, (ill i‘n space ater
Cemetery \cfN'-g... \.d.l,9.3 Date of Burial ,L b l . 19 7.),...
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated 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 the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PE T
(Name) CCI (A iess
the � �'/
1. to hold temporarily and the body
( taker or person having charge p of cor e) Inter, remove, or otherwise dispose of (state how))
Dated . I { .�19 .7.) (Signed) .... . ..
or
111
This Per is sufficient for the Removal (and Interment or Cremation)of a bo to any part of the State subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit ermit(VS No. 62) is required.
FO'ltM VS. 61. (REV. 6/63) (A2-248) ,
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADEaee
7006
Date of 4A014- ' was J,� / 19 S
(Interment or C ;a)_ V
(Name of Cemetery, Crerrar
Section ,5gp Lot No. 4i�'4 Grave No.
//
Sot (Si ed)II ft
yy ' , (Person in Charge)
R4
Address .
Person in charge must return this Permit to the Reg}s rar
of his District within SEVEN (7) DAYS from above date. If
person is in charge, the FUNERAL DIRECTOR or UND ['"
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
2 SEXTONS, FUNERAL DIRECTORS and UNDERTAK
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 required, under
penalty, to report violations thereof.