Carson, Russell Form VS.Cl. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF TE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.
/ Village— J •
Dist. No.2.1.; ‘.. ' County ..(----C.........-,mt.i--- ?---e---r--- or City give
V .
- --7 4 (If c. , give street add as)
Name of deceased .. . .. 2- ?,L. / .. .....C 1,.‘.-. -xa. A-Nc------" Veteran
Single, married, widow
(If veteran, give name of War)
Sex.....,.. . .: ..Color or divorced (wn
tethe word ..... .. ...Date of De1.47..../ 7 ..
.. 6/# . 19 ..
Age..e./ Ye Months , Days Birthplace ---V---t-1---r- - o(." 2. ... ..
Cause of Death ---,--,..,
r.:
Certificate was signed )r... ...... ..... . ... M.D.
Address /
Place of Burial or Removal)..........."•----
(If body is to be arily held,fill In space later)
Cemetery ------' --(-- 1: -..',, . -s---1.--,e„ 1..-1.4 Date of Burial.. / —
(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 forion, have recorded it in my Local,Rec d with the above stat Re istered
Nu____ r.,7___eand on e has' HEREBY GRANT A PERMIT
i3 /
,1-
to
i----, (7dress)
the 1\--(-1--(_,-
o hold tempora ' an
Dated
(jnytliirer;ran having charge wpm) In re ove,o the __67.Zte:f. w])
192/ (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b,6d71to any part of the State (apubject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Yranait Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o / 19 6
(Interment or re tion)
(Neese of Ceaetery, Crematorium, eto.) J
Section ' Lot Nog'?( Grave No.
(Signed) 7....77)1,/,- -5te _
(Person in ehe se)
Address / 6' t G� 9A
t"' -/' 1
;4IK
Person in charge must retur this Permit to
the Registrar of his District within SEVEN (7) DAY
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.