Norton, Charlie .,r,-.-+ vs.s� NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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.__.. .....V.............
/ Village'
c.
Dist. No.. : oua ....:.......ty14,,aCi!1 or City-
(If city, give street ddress)
.Name of d ceased ... . mm*1�z 1.,,I.r ..., 6.V 1";$4 .. . Veteran
Single, married, widowed, (If voter are ame of Wsr)
Sex. .. Color. . "r divorced (wnte the word) Date ea � I
Age , 7-.. rs Mon Xjirthplace. 1 , ,
Cause of Death (e' . .... .. `> ',I
Certificate was siglle by •• .• •• • M'+'
Address ...... ...I...,...
Place of Burin or Removal)
(If body is to be to porarlly held,fill in spec
I r
• Date of Burial
Cemetery.... I "'�
(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 exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ac ted the same for registration, have recorded it in my L cal Recor ith the ve stated Registered
Nu , n the basis thereof I HEREBY GRANT A PERMI
to ri)nk .
the .. ) to hold temporaril d the body.
(Un rta r o n having char corpse) (Inter,remov o �dl oose of Es w])
Dated .. I IS .e (Signed) `
Local Registrar
This Pe t is sufficient for the Removal (and Interment or Cremation) of a y 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date -- ...' was _. G_3
C (Interment or
(Name of Cemee ter y, Crematorium, etc.) J
Section Lot No. Grave No.
(Sued) ,� "-- T ('6
(Person in charge)
Address ^ l( f____,C,1-----g-T-
--- �'��{
/
Person charge oust turn'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.