Skellie, Olive -or=VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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.__.._4'......7.
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Dist. No County � ��'�`►h�~"�.. or City ���s�-�---1 : 9
/' (Ift city, give street addree s)
Name of deceased 0 . a,�,t + `/-'& Veteran 11, ''
(if ve�ersa, five ame of Tar)t�,, jj Single married, widowed, iry 1 ,)
Sex.'/4 Color..CN or •divorced (wnte the word) `"�' �"� Date of D th ', �t •o•19 ....
Age L� Y Months Days Birthplace0� r + •• •� i
0,4
Cause of Death_... .. : . ti' 't a�
Certificate was signed by L' M.D.
Address /i1.. Q... ° -
Place of Burial (or Removal) � � rti l.. � 1 Aid `-
(If body 1e to be temporargi]y held, fill in spa later
t. 2 .'- t k c-- M Date of Burial ilrv-',_'``� 19
Cemetery .r.t�..�
(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 for registration, have recorded it in my Local Record with the ve stated Registeredj
Numbe1r1, and on the basis thereofof I HEREBY GRANT A PERMIT � � � 7
to .1:-X.t ' tj.-43{y �j .Y t .,y...... _L (Address)
(Name)
the - '-'Y t"�-�i'�—tt -`�'-- to hold temporarily and VVV"'�""�" the body.
(IInd er or person bgy 19 ng charge of corpse) -ier,remove,or otherwise dlsoose of (state how))
Dated I (Signed) )..e.e. : h Local iFt•gis
trar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pest of the State (enbject to local
cemetery or other regulations),unless removal Is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEUENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of/,,. rme was 19
(In merit or Cre tion)
(Name o Cemetery, C emator um, etc.)
Section Lot No. Grave No.
(Signed) ..��
rson in charge)
Address V
Person in chap must re this itC ,
the Registrar of his District within SEVEN (7) DAYS J
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.
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Owner
A\iRc \ LOB
Address Pl t
Phone # Lot #
Deed # Date
Cost Foundation Y - N
Location
b.) G.?. U) Gv
Remarks .4\/. So,�e vc
709' 'V' Norr ib bpr� �h m�sl�ee.
Record of Interments
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