Jones, Forrest Form vs.El 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
17°1 County U1'ton or
City
G1 oversvt I e
ity
Dist. No
(If city, give street address)
Name of deceased Forrest E. Jones Veteran W.W. 2
Single, married, widowed, (If "" give name of War)
Sex M¢J0 Color Wilt'teor divorced (write the word) 1%`arrted Date of Death 4pz 1...22 19.63..
Age 4 Years Months Days Birthplace (UBI:ta...N.'sk1,.B,...N.Y.
Cause of Death Aclzto M.11g.cqrigga Fqtj ro
Certificate was signed by A, GgQ44/1 M.D.
Address G.i.R1/.0.1 rS.V.tl.Zg,.../l.e.T.a
Place of Burial (or Removal) GX.eng...F.'aX.i.s,...h...Y,
(If body le to be temporarily held,fill in space later)
Cemetery P>.r1a...t!.t.ew...C.C1 Date of Burial Apr11..25 19 63
(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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to ,K.ermedu.. 'xznena2. S"er..v.tae G1A.uarsvU?ie Ii<..Y.
(Name) (Address)
the .tindextaket to hold tempor ril and in:t8 the body.
(Undertaker o�gerson having charge Qt corpse) (Ibt ,remove,or otherwise disnos state how))
Dated pr-(0-1 �, 19 t�' (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a o 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
Deity) . .ZL. 19/—
(In te men t or
/- (ame ..f Cemetery, Crematorium, eto.)
Section Lot No/Z rave No.
(Signed) J Cry /
(Person in charge)
•
Address % ��l ��•__-����� �c ..
Person in charge nnlst 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 OFI%NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.