Wright, Garrett Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ca This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) 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 CT,!
S ( �_._-�-� Village 0 LQ Ems,� c n
Dist. No. l Cotmty �-� or-Gi
'� (If r+� 1ve street address)
Na e of deceased �:'.../1 &EY ( ! „ , iti..1„ Veteranc ` �Q Single, married, widowed, (lf veteran, give name of w.r)Sex "`-'Color 'or divorced (wnte the word) L.. ate of each...,.... . — / L1 - 19‘,..
Age 1. Years ,. plonths ..... ys Birthplace ._
Cause of Death i'-'-'- -''�: •i.t .,:,
Certificate was si 1� :r:nn 4:::C.. ... .. �r.-. M.D.
Address . .:�k�.. .A... 1 „13.. (--/..(.: t Y 4 e :. .RAIL--
Place of �(or Rem val) v
(If body is be poraeily he d,fan in ace e)
Cemetery ...,h '...,A -L-Y Date of Burial I 19c
(If body is to be temporarily held,fill in space later)
Th4 Certificate of Death containing the above stat 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 Record with the abov stated Registered
Nu , o ith -bees" t ereof I REBY GRANT A FERMI n
t0 f. IDe) J (Address)
the .. ... . .AI .s.::,, to hold temporarily nd 4�,-,- the ody.
(Uncle ter or pe g char of corpse) (Inter,remove,or is ose of[state bowl.)
P avin C
Dated /• 1�, (Signed) r� k ,.., ,• c. . .,.,�
f Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bold to any part of the Slats (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 PE3S3N IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date �'y' N.• was 19 -3
.^y
( nterment o
111 ITo
:.....". (2j:."1"--.1-4--."--d1 1 . -..__.
um,
a-11_4/6,C1/-.0C„
of` r , Cre tori Jw �
Section Lot No /q
4r Grave No.
y
/fL6. It e
(Signed) :/G - -' ; `
/ee/. /1-'- a-0-t-.1'-'''/'
C (�'��Pe-rss'on in charge)
(/(i.f
Address rI ,_,----&:.---_--4<-
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.