Fielding, George Form T8.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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—..7.1. _
`—. age V���� \Z q�-e-�
Dist. No f County.....,f. :x :...........,, orVill City
(If city, giv ,street address)
Name of deceased... ... / �� ' Veteran.
Single, married, widowed, (If veteran. give name of War)
Mv"Sex....... ..// ...Color P v or divorced (wnte the word).....7:J . . .. . . . Date of Dea �e�• / 0 19.4.:3
Age Gp- / Years. Mo s ... ..Days Birthplace a ='�.�_'• '=7k� :Q:z...yj..y
Cause of Death 2t1.-`''--a.- :?
Certificate was signed by..../ M.D.
Address
'. ->) - y .
Place of Burin r Removal) Vs: :-..:(..,e,-- _,_,, e-7..-4,7- �1...�
(If body is to be rarity held,�l in.space iate Cemetery . Y.. ....../� --`�' . -21. . Date of Burial �:/- / Z 19 6 3
(If body is to be temporarily held,Sll in space later)
Thq 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 acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on the basis thqeof I HEREI,Y GRANT A PERMIT C� 7 ZYto /. - n...- , .,., !�:71�... .... a) 4.. . (* ms� (Address)
the f �/t 4C�� to hold temporarily and... the body.
(Unde er or,oenon having charge of corpse) (Inter,remo e,or otrise disnose of(state how))
Dated --/..... , / 19...G.ti. (Signed) t ti•'
al Registrar
This Permit is sufficient 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o--/ was if "—- 19_
(Intent nt or ce
). s d,
6/4/12-...,-- .••••<:::---e---t:-1.--,-....-- _7_,,4..._______L,_ _
(Name of Cemetery, Crematorium, etc.) 7
Section -75' Lot N2-2- --2 7 Grave No. \S---
,
(Signed) li -�7�''
(Person in charge)
Address 4F' W� '-'e--"' ,v -t:"`s-i��;c35L.
t---
___,Ac _-C--',1,—::=3, ---77. ---- 6 ....* -7.- y
Person in charge mast 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-
RENT, 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 ON'Nr,NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.