Duprey, George •Ma.•• ■VMM *DI MIG I/GUMMI Ia GI1I Vr r•mi.u.irs
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar' 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /i/
Registered No.
�� %// '�� Town, Village jj-C= 'Z
Dist. No. - jCounty or City
L 6n If city, give street addr
Name of deceased_: X__e x � Veteran __� a Zi�
,.✓ (If veteran,give name of War)
J Single, married,widowed,
Sex ° /`" � or divorced (write the word) 7)4.-1/v.�,-. Date q Death _ _/37 19_ �_
Age ��-„- Years Months l Days Birthplace '`--6�
Cause of Death r _ c= ' - ct -e-� __(� :-c. a ,f,I -
Certificate was signed b ✓ M.D g Y/ i _
l"
Address J1;( _' �� ,i� l % /�,
Place of Burial (or Removal �-r -A. c < (/
(If body is to be porarily held, in ace later) / }
Cemetery Lc L l __ __ _ ' Date of Burial 4,7.41
19__7-'
(If body is to temporarily/field, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regis ation, have recorded it in my Local Re7rd with the above stated)Registered Numb, and on the basis thereof I HERE-
BY GR %ERMIT /'
fi
{� (Name) / (Address)
the -Z( - �-(-1 �-t/ to hold temporarily and /-C 2-_. the body
(Unlerta er or p son having charge of corpse) (Int remove o other vise dispose of (state how))
Dated /,--2 19__Z. (Signed) l eg�s ('�.
catraf"
This Permit is sufficient for the Removal (and Interment or Cremation) of a ody to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (4A2-179)
ENDORSEMENT OF SEXTON O2 PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was at�'C-%74 719 7
(Interment or-Q.ima'_ an.))-
41-e 1
(Name of Cem tery, Creazatpriun, etc.)
Section Lot No. Grave No.
4
(Signed)
(' 4"--1A-ffrtri-t-----
(Person in Charge)
Address 6?)') /
Person in charge must return this Permit to 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 STATEMENT,
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 UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DQLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.