Norton, William Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir 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 alter the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__..;?-../
Village //�///
Dist. No County '(.�VI'/ .or--Gib `'I: !2,t., eLti t,,
(If city, give 7t t address) ,-_�_�
Name of deceased ..GL. .S,.d:`�"'4 �' A'tSitie-PA/1 Veteran / -----
,
��� Single, married, widowed, f� - (ifs°r"�. give name War)
Sex... . �.. ....Color or divorced (wnte the word)...leG. ........ : Date ofD�ath...... .. .... . 19.�J..f
Age l ic, Years Months .....Da s ue , Birthplace J/l.14.ht 4... �, �r 2 G.
Cause o¢ eath ,a: I44 .
Certificate was signed y....zz,, ..... <-4., 1.. M.D.
Address . ... ..�� ... - i4.,. , ) ,
Place of Burial (orRemoval) . �. t., .. 4:2:`.?...yT�..C::G.
(If body is to be temporarily held, fill in space later) .. --- ;
L ,
Cemetery -- - Date of Burial "‘"z 4- 5 19
(If body is to be temporarily helRY,lill in space later)
The Certificate of Death containing the above stated particulars, having been presented 4 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, and on the baa %
hereof J. HEREBY GRANT A PERMIT '
to .
7)--e=e-a4e.._ )2s :-/
^�l,, ps ) ddre
the Yi.k.,—ie - G,e., to hold temporarily an L...2d^ ✓ tFie body.
(Und taker or person having charge of corpse) ,remove,or otherwise to I)
Dated . 191 (Signed) ,r�.,64,-� - ,.. * 6/.)"....
Local Begirtra=
This Permit i sufficient for the Removal (and Interment or Cremation) of a body to any peat of the Slate (eubject 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 INTERMENTS OR CREMATIONS
ARE MADE
Date �
! ',` ,r w jZc O 19 `
Interment or Crossett
-j7
- L -74€c z�7 Yfr(' —�� 4
(Name of Cemetery, Creme torium, .ete.)
Section Lot No. Grave No.
;,i--- -, _
(Signed) � 4e ,-- - . -see . - -
(parson in charge)
Address61 'i/'�1 .e-,.--' _ /
Person in charge must return this Permit y
the Registrar of his District within SEVKN (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.