Ayres, William Form VS.St NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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 OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._...a+C.�gY
Dist. No S1 c I' ,,�J Village 7 County....(,dl. r.'. ''4 or City .. .T. . emu
(If city, give stree /d�reesss)'
Name of deceased.... Veteran
`-- s-e
� Single, married, idowed, (If veteran, give name of War)
�pp�� 19 !r/
Sex-.3(it L.ekolor ..or divorced (write the word).. .. . .... Date of Death '"
Age IS Years Months Days • , Birthplace'? -1rrl.� au
Cause of Dea �t^ti�,a:is�fli4e./.7...6 : C G.. ./.... 1. . .. .
Certificate was si d b �^-�� f �,�..a...(r(1llitit,.tac? .. r. M.D.
Address &?, - � .C..,f...x.i 't--�
Place of Burial (or Removal)
(If body 1s to be teperarily held,tillAs spa later)
Cemetery I /. 4.44...A 1 ..Date of Burial
A7-- 19.(.41/.
(If body is to be temporarily held,fill In space later)
Thn Certificate of Death containing the above stat 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 regiistjation, have recorded it in my Local Record with the above stated Registered
Nu , and on the basis thereoF HEiREAY,RRANT A PERMIT 'S
arm) u. ddress
the to hold t poraril and the body.
(Undertaker or person wing chargee,or of corpse) (Inter,re ov o se dispose of[state how])
Dated '5'' s--' 19.E 1.. (Signed)
Local Regis
This Permit is sufficient for the Removal (and Interment or Cremation) of a Ito any part of the State (wtbject to local
cemetery or other regulations),unless removal is by common carrier,in which case a ansit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o� ,�L C F%3-ri“�_4 , �(C<<' 19 L�
J /�
(In lopeuC or Creuatieifi
c //7- ,
l .. J
(Name of Cemetery, Crematorium, etf`.)
47/6c1.1-- / 0 J
Section LOt No. c.„._ Grave No. 7
(Sued) % l/2fr' /--e�G ( '
(Person in charge)
Address C< i C x „.....e,:49-
•�i /- �-
Person in charge oust return this Permit to(
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECCTOF 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.