Nichols, Winfield Form VS.SI NEW YORK STATE DEPARTMENT OF HEALTH A "c2_ 9
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr 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 DUR 3 BLACKA .--.-.._y
tl''"M i;d To ag �-i T 11 S � �1 r.JPIo.
""�� Vill e p_ + t
Dist. No_u.i. .JCo ty. or City
d o " p � (If city, give es)
Name of dec sed. / ' . O -• Veteran .. .
:ngle, married, widow , , eteran, give name /
War)
7
S . . .Cr,• '.. 6 divorced (wnte the word . . .. a .f ..` �... .. • ... -..19.G?...3
Age (5.Years nthsIv
Bi . ., .".0
Cause of Death / // �...
Certificate was signed by ,• �a� ,.. ' M.D.
Address - �,•0 - N.
Place of B (or Re dl`L1 ..Apo, �•• • ��/
.;.�
(If body is rar lyl space /�Cemete � Date of B •e,=6 •••�• Q/ 19..,.�
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having bee/.resented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATIS CTORY AS REQUIRED BY LAW,
I have accepted the a e for registration, have r orded it in my Local Reco . with the above stated Registered
Nu one ba thereof*I HEREB NT A PE' '
to („e 1,.. •
_... �/f / I. —%♦ ! • ~'
� �, •.�/•,,
the ...to hold temporarily . - ' .. Or ! ."7. the body.
(tlnderta or mon ha n chargf corpse) (Inte0 -•.ove,or othe o. of[s is how])
Dated i .. C$ ee�v..19G., , (Signed)
L�it� at Registrar l ' /
This P 1 is sufficient for the Removal (and Interment or Cremation) of a body to any part of e - �.►f b,e. -� •ee(
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 1'/ ..,•_, A,. ••
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CITATIONS
ARE MADE
7
Date ' w!3' 19 g
(Interment orjCr Lion)
-&a2r.„ /-2..... /L7-e_z Gam.- G�sc(NA Cemetery, Crematorium, e .)
Section Lot No. Grave No.
l Signed) �6?zD41-4*-- --- i C �/j�'7
(person in charge) "
� � /J f 'f .z---,)' ._._(b,� 1
Addre
7
v
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.