Wanster, Louise 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 COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK Town Registered No.__.._.(2 42--
e I7C
MI5 �oO �Dist. N County � a-,�-„^-c's``- oarCty .... ... (If city street address)
Name of de eased (.�N Veteran
/ Single, married, widowed, (If veteran, give name of War)
Sex Color...a—) or divorced (write the word) ' ....Date of D ath - 49- 19..6.22
Age ....Years.3
..., Months Days B' place.... ... ;7 ,.‹.,/ i/
Cause of Death ..
Certificate was signe y...:. i M.D.
Address< ..
Place of Burial (or Removal) e"-"..9--71 �, ->:...
(If body is to be temporarily held,fi11 In space later) i _ L ` /
Cemetery > %—2- -i..e.t„a.: Date of vial 19( ?..3
(If body Is 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 Re or ith the above stated R gistered
Nu . :'7. • on the basis t f I HEREB,ld 7NT A PERMIT C E O' -���/j`
�/
(N � Address)
) Ce.
the �- ��4 r to hold temporarily nd the body.
(Undertaker or�p�e °n having cbarge/df corpse) (Inter,remove, r othe disvose,of)(state bow])
Dated ,..� "/ 19 (�' I (Signed) Re .4 �
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any art 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date y- Lt i was/.�C'�-L� 19 ‘ 3
(Interment or C mation)
(_:::;;-- 7
1
/h am= 7/7
z. . 4, .� - z 71r17:—•<..-e kr
(Name of Cemetery, Crematorium, etc.)
-- r-"__
Section Lot No. Grave No.
(Signed) ` �(///��"ZF'
(Person n charge)
•
Addressa C r.„' G= .2- r. `j _.
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 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.