Ainsworth, Theron y'orm vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING end acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.__. /tyC
Village
Dist. No....3294 County..._..0.tiFxI)A. or City MM Cy
(If city,give street address)
Name of deceased Theron Ainsworth Veteran no
(If veteran. give name of War)
Single, married, widowed,
Sex male Color white or divorced (wnte the word) widowed Date of Death �'I� 19 4'4
Age 77 ears Montrs r. .Days Birth ] ce Trey New York
Cause of Death - A lLt t� >< X �� tse t SM.. ' '4�rrr-fs�Lr4C+,,,
Certificate was signed by ,,// M.D.
Address 1 4-f�4.�.t� PGs�-L Kt �c.h,+� ` Lire
Place of Burial (or Removal).... ,,
(If body is to b mporartly h d,fill n s ce later •' / -�
Cemetery... f �4 .... �rc�'!./� C � Date of Burial.., c J 19 ' ?
(It body Is to a temporarily held,611 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
�erreeogistration,,have recorded it in my Local Record with the above stated Registered
Nou& .t1, (.�1.-4..on basis -6d. f�zei .. .'N7 A PE T tY . ..�j'.
,� , � �-' p "6") et
� '`� tedareaa)
the..� > a% to hold temporarily an the body.
(Uutesta1 r or person having charge gt corpse) (Inter,remove,or o erwlae ilanos Late how])
Dated.,, �� c .s � 19.C �'• (Signed) d.�'
Loral Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (rbject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSE ENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o -�, �-�__ w � 19
(I Lenient or C emotion)
(Name of Cemetery, Crematorium, etc.) J
Section 7 Lot No./ 'Z5 Grave No. /
(Signed) ��{ 'Z,- 7(7- (�1'l�Li�.:t
(Person in charge)
Address J /7( < -•� 'l
Person in charge oust 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.