Wakeley, Edna nGWV 116/11n aIr11c se/sr-Ping m&n. yr r/CA1.1 I,
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I[ 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No.`'-' `"7,
Town, VW ?
Dist. Nose - %,' County or City % ,r�: _ ---.---
If c' y, give street add
Name of cease( '�1i .E)
_- - �_�t� .Gc. � Veteran.-- - --
n (If veteran, give name of War)
Single, married,widowed,
.•Sex . .-.-- - --cu( or divorced (write the word = .‘,ti4 " Date o Death ...-,/,/----(,7 19...26
Age/i 47 Year Moat: Days rthpl
Cause of Death -�.�- -/. f�1'---z'S ... . Cx- .e - -
z. (((
Certificate was signed by ict."
1 /U✓; M.D.
Address !po l_�' _ � '/
7,7
!� /
Place of Burial Removal) _ ,,- _ _ -- Y�rr�� �
�
(If body is to be t arily held, f'l in spate late ) -
'Cemetery _,,.zC-v -___C/rL.G .L Date of Burial ..,�,/- 19/6
(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 examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
ation, have re ed it in my LocaJOd with the above stated Registered Number, and on the basis thereof I HERE-
BY r t A PERMI
c4)7
rie„7,4-- I_ i - (Addrss)
the r.::_ ��w ,--
���� to hold temporarily a the body
( lertaker or per-. vi charge of corp ) ^ Inter, mov t rw' disJ a tate how))
Date /11- Pi 19- - (Signed) __---. .67 � �s �
/ Local Regi rar
This Permit is sufficient for the Removal (and Interment or Cremation) of- body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date o was c 1--(74/ // 19 Ida
(Interment or ere errr—
(Name of CepaiterY, Cr ---
""e /vim!Section / f Lot No. ‘Pi
Grave No.
(Signed)A<Cit,\ `
(Person In Charge)
/e•-)
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 STATEMENT,
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 UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.