Pettit, Edna roan VS.41 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,
(illate, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN BLACK INK. Town- (,----irx, Registered No............... ....
Village „I
)ist. No /....County.. • --trr City '
.7(.1f y,give address)
atne of deceased(itr--#. e) Pati..t eteran , ,./ IV, 4,/,.-741—
N. 1 44veteran, give name if Wu)
Single, married, widowed, g.,
o .or divorced (wnte the word) 'el' Date of V,., "3
,---- • ../4/
'7
:ause of e?th L--,C••--ft .-C. .. ....tette-a, •,t•
. f
:ertificate was si e b .....‘. " 1...e...... 1 M.D.
Address or C.' - -.gees-V.
gykl
r 4
' '---?t I --"4'4" ' ,i libiA4— Xrellitty \)P/
)lace of B Vin.cor Removal •
If body is to e orarilyilieldr1111 in spa e la /
;:emetery ....A.3 Lk: 1....1--C..r...L ---
i
ate of Burial 1 Cf, 19.‘.. ..
If body is o be temporarily held,fill in space later) i
['he Certificate of Death containing the above state articulars, having been presented to me, after careful exami-
tation, the same appearing to be COMPLETE, C RECT, AND SATISFACTORY AS REQUIRED BY LAW,
hay cepted t e same for registration, have recorded it in my L ecord ith the above stated Registered
iu :basis thereQf I(HEREBY GRANT A FERMI ,‘ ,E-.t4 ' - r
D. .X.i-. 1 .1...e k-i, i-4.--e...,
he.. ( • '
t ..to hold tempora and )
the b.• •.
d tex o 7havin chargef;Tpse) (Inter r otherwise diseef[ i)
Local A
This ermit is sufficiZt for the Removal (and Interment or Cremation) of a body to any of the State ( bject . local
emetery or other regulations),unless removal is by common carrier, in which case a Transit P r 1 (VS No. 62) recite •.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of"-- ". ,1... ( w 19
(Interment sr Cr )
7,l";:_c_- ..i'z,_,,,- ___ C. G":) .-2--e_ (,--2
(yi
(Name of Cemetery, Crematorium, etc.)
// ry
Section �`� Lot No. �(s�-� Grave No3
/ 1
(Si geed) /2�',fy4 --� _.._.l `�•'C� iT7 L
(Person in cffirge)
Address 6) C `/ if— .C=t'.'
Person in charge must return th s 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.