Demarsh, Jeanne Form TEL!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can be signed only by the Local Registrar (Deputy or subregietrar) 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. TOWPI Registered No.__.._...._........._..........
Village
Dist. r 0 County 'i•. 4- R . C o . or-Cit}r C A - , ,—
(If city, give street address)
Name of deceased —,l..iw/A.,v ,!. J.c. L I. RI-'). ..1... .M.A?:S.(-1... Veteran is-4 Q
(If veteran, give name of Wsz)
Single, married, widowed,
Sex.F!r.M.gt 4.E.Color O ,7-4 or divorced (wnte the word) la., 4 c---' .Gt....Date of Death &c 1 2,2 19.6
Age 7 1 Years Months Days Birthplace +(LA As c..:Z,Cause of Death Q 42c-, ,c MA o F. �L C. o .v wi.Mg..i.tA. .-"fA.S.. ..5 -4- NP.�4,a7s c......!.."I .,c''t F Fe c , 1y
Certificate was signed by Da-, {-, :S.f.. .0 C......!11:1.< 4--c..411.0 M.D.
Address CA ro , e4?.A0,,-3 `Z4p 244...,„
Place of Burial (or Removal) G L'=N Ns i=A'-'-S i N c..v Lea P.A..,
(If body is to be temporarily held,fill In space later
Cemetery..., r. R`P H N. .s4... t 77 M E ra 2-1 Date of Burial pc ' , 3 I 19. 9.
(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
Numb , and on the basis the ( f I HEREBY GRANT A PERMIT
to (J.-) 'c_L, A /� E. , Gy 'I—i=A CI— ^ � A nJ T'� "7 A..) .y
•
(Name) ti (Address)
the....�t.<u.. :.:...R.,TA 1<.c..2 to hold tempo ril and.\ ' a.1?", the body.
(IIn4rtaker or person haying charge of corpse) / (I ter,re ove,or otherwise dispose of[state how])
Dated c ' Z.2 .r 19.1.o..l. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation a y to any part of the State (sabject to local
cemetery or other regulations), unless removal is by common carrier, in which ase a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEX UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
•
Date of -> was C. A`-/ j! 19 6./
(Interment or Cremation)
Lr
(Name of.imetery, Crematorium, etc.)
Section 1 57" Lot No. Lc" Grave-No.
(Signed)
(Person in charge)
P
Address I
er2
6UU
Person in charge must return this Permit e9f1-1.",14
the Registrar of his District within SEVEN (?) DAYS „/)
from above date'. If no person is in charge, the `r �l/�.
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE /,
MENT, write acrpss the face of the Permit the words ///e
"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 1 w 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.