Rushford, Marie storm vs.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lr 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,Qg
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. _ Town ;pRegistered No.__$..&' J
Village
Dist. No56 CV County..._............... - or -J' G' 1'cc &:JJ
re?,19/
rt t add
Name of deceased 4* Gam. ,�6. * ... .. Veteran
Single, married, wid ed, r (lf vets n, give name of Wu)
Sex Color or divorced (wnte the word)/* ate of Death...:. -e--c- a 19..6 P
Age 5..7.Ye s. Months Days— Birthplace
Cause of Death ,
Certificate was signed by..),.. - � � ,.. , M.D.
Address -
Place of Buriaj. Removal) `%�
(If body is to be m rilyNheld,fill ins liter)
Cemeter
y ...f(--:.:.....,.�' .. . . .Date of Burial.. ... .... ... ..� 19.(,G!/
(If body is to be mporarily held,fill in space later)
Thq 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 he same for registration, have orded it in my Local Recor with the ahoy stated egistered
Num , the basis th f b HEREB RANT A PERMITcl_'2".
G_
sadr
the - /Y.N.,e ,444=-4 to hold temporarily an . d
.. .
( ker or pe a e;
having charge of corpse) (In ,remov -of"otherwise dig a of(state how])
Dat . .. . 19.. i. (Signed)-. _` .--,-=--,„ -?,,.,r-,_._
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ("abject 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 of � es -.- was : 19 '
- .. (In terment or )
r L (Name of Cemetery, Crematorium, etc.
/ J l
Section Lot No._/ !� Grave No. •�
' /7, &
(Signed) . � - u�L
/ (Person in charge)
Address
7)0 Person in arge mus turn this Permit
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.