Bissell, William Form VS !IL 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 COMPLE TE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK
Town Registered�slezed No. //-- -- -- 3.-.......- .._.-.
f / -., Village
Dist. No ('Cl/ County k:»�r or City (if city', give street address)
Vame of deceased...... f , s -� r /y i' Veteran -7-1-4.-
Single, married, widowed, i i cif veler#n. give a War)
-ex............(...Color A.
,, or divorced (wnte the word) /%- Date of Death ... .. / '-' 19.G 4--
.ge `....Years Months Days Birthplace / ••
:ause of Death `- -C..-e.-... :`. ::7.13:i: : _cif..,A-7-[7.-e,-, �,.E '
:ertificate was signed by . :, . .4:.tG%: c �,. M.D.
Address r 11 c;.--‘: �/79 •/
Place of Burial (o emoval) ,l b�''7 1 r - ..t.-tz-=- -c'�c�--`` -"�
;If body is to be tem o y held,fill in space later)
d
Cemetery .✓,,4.:,: f:.,.-.,.,s:............c.,i,::,.- Date of Burial - 7- J �- 19:�.
;If body is to be temporarily held,fill in space later)
[In Certificate of Death containing the above stated particulars, having been presented t me, after careful exami-
iation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, ' on the basis thereof I HERF,BY GRANT A PERMIT ,
he L:'4l..1.-mot/ . to hold temporaril and... /4--6- (Address) /// the body.
(Under r o peRgi having charge ypt�corpse) (Inter,re ore,or of erwise disg4ie of[state hcw))
Dated . : }� ( // 19..&.2" (Signed) j. '•- --e' � Li, "t, .-p-----.''
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (srsbject to local
iemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERME[dTS OR CREATIONS
ARE MADE
Date o -77 9 '
Interment of
'-)/(
(Ilene"of Cemetery, Crenstoriun, etc.)
Section 2 7 Lot No.5// Grave No.
r
(Si g�led) ,/�`/2f- ,� _
(Person in char
Address c ?.
Person-in charge mist 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.