Jones, Asa Form VS.II. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit tan 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-.1... .i...X............_
Village
Dist. No ,5--‘.qt.Coun,_i7.1.7{.a-a2-e---7t-- or City 47.,,c2d- \77R/e-ci
Name of deceased . ---2--arr.L-797 -4.-
kz Single, mar , widowed,
,h. ,--41-11r-e
' (Ifyciet3;e,rgaivne strjggiiiddrees)
(I eteran. give name of War)
Sex. ........Color. ,a" or divorced write the word.).-Y2-7 ---,--?-.1-e--e/Date of 9nth 4.-- i_._6' 19,4 -,
Age 6-6) Yea Months Days Birthplace p<.....:/-.e762-47-0--ii/
Cause of Death
Certificate was signed by ' .. ..--7-2,- 1:-...'.2.-4_,— M.D.
Address .4 7--'-e- )7 A'
Place of Buri el..- ,r Removal) -7.-.-Org:?:2. 1./ -....—Z-la .17-6. ' ' 7
(If body is to b fill orarily held, in space later)
Cemetery.... .4...-V4.-e°- 4./,;44,e,-- C-41,---1-71 Date of Burial /-...? 19..( 3
(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, a ter careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I hav accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Num14, and on the basis thavepf I HFREBY GRANT A PERMIT
to (-1,011.4 -
th t 12.e.d2.9e (Address)
ric- -7,-. to hold temporarily and.. g..7.
the body.
(Und.taker or person having charge of corpse) (Inter,re ye,or ot; se cliigose of[state how))
Dated i.'‘• ... .‘frar.......... AT-Y1
19.6..3. (Signed) A. t..1 )
This Permit is fficient for the Removal (and Interment or Cremation) of a body 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 SEXIDN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o was 19 eL3
(Interment or
` /? -
6r - .
(Name of Cemetery, Crematorium, etc.) '--
G
Section 2— " Lot No. Grave No.
(Signed r �'��^ �' �yt�(
(Person in charge)
(TPAddress ( ( /a (1
Person in charge must return this Permits ,
the Registrar of his District within SEVEN (7) DAYS
from aboNre 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 OFFlNSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.