Mingo, Alton corm vs.E1 NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tt This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
'illaga, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__.....__./..
4 Oneida. Village Marcy
hst. No...,2.9......County n a or City
(If city, give street address)
Tame of deceased i/2CsA[(.... .J 44:1.`? Veteran
Single, married, widowed, (If veteran. give name of wv)
>ex -.a Color id4!` or divorced (wnte the word)....c7 ..1e.."I.lel Date of Death ////t 19.. .2
i.ge ., `' Years '7 t ,If on �.l.S.:.»_ Das irthplace.. kez•L „ . ..1/i
;ause of Death rGr 'l�jt �x.I ice►^: L.( v I4 trlC.�,
r ..,
;ertificate was signed by M.D.
Address .�/•'f: •• .. .... •• ••• ` !�l`
'lace of Burial ,(or Remov
if body is to be to ra a 11 in space Iare t
�emetery .r,c. .... . . .. .. .:>af.. rr:..r... w'+ ( �y� '" Date of Buriall'i.41/7 /`�i 19 g -
if body is to be temporarily eld,fill 1n space later) /
be Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
ation, the same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
have accepted the a oregistration, have recorded it in my Local Record with th -stat egistered
(umber and on t� ,r
b is' ereof I HEREBY GRANT A PERMIT?j 6e,6. '4
(Name) (Address)
le 'a to hold temporaril nd the body.
( dertaker pe q4li■ arge of corpse) (Inter, remove, r o se iso of [state bowl)
)ated NI,'"' 'f.. `/ 4-2" 19 (Signed) !s.4 'J. .,2 ..a' 4`-.4-..•
ep•Local Regi
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (subject to local
emetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
I
ENDORSEMENT OF SEX'UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMNTS OR CREMATIONS
ARE MADE
Date of rtLrv�-'v- was 4/./PLY . 19 6?..
(Interment
SX ,.�.�..�.
(Nana of Ce y, Creaatoritia, eta:)
CI lI
/ll
s \ $
Section ✓ Lot No. Grave No.
A....4.0t_c2-g---66"<-.
j
(Signed)
( rson in charge)
Address
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 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.