Seaman, Eva N I W Y OKK Si Al h 1)IPAK I MIvN I Ut' t-tAL 1 ri -- _"/%`
OFFICIAL BURIAL (OR REMOVAL) PERMIT �C V
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN RABLE BLACK INK.
SA9 /� (� pN �/Dist. County. i! or City . RA.I..OGA S?. I �d; - N. 1--e...
�� /,',,,,./� J• (If city, give street addr )
i me o ased. �.e.Gr..a >,.. . !' '., . . Aff." Af . Vetera -..a
(If veteran, • e name of War)
Single, married, widowed / . i
S or divorced (write the ill /.. I Rate o •.ni+ if
•
Age 77 Years Mo' s %i ays Birthialace.
Cause of-Death .. .-. -' �j
Certificate was signed by _ v , `/�, M.D,
Address �- / .% - �,do .�
Place of Bu 'al (qfl +_ =% i r ��' !
(If body is t poraril hel�ll •�r,: er) ,4k //
Cem /... . ....• A, �% / ...- -...Date of Bur _ ,,f _ /r__
(If body is to be temporarily held, fl In space later / 1
The Certificate of Death containin-/the above stated particular having been presented to me, after careful exami-
nation,•the same appearing to be COMPLETE, CORRECT, ' ND SATISFACTORY AS REQUIRED BY LAW,
I h. •• acc:'ted the -me fo registration, have recorded it in my Local cor ith . 'we s •t•• Re ' tered
Nler, • .d on the la j,/reof I HEREBY GRANT AJ? �.44r 4��� dOrJ
r/ ,4,`
he to hold temporari ..... .. .... the bo y
(Unde y /� rson hyyng charge of co c)i (Inter, re ove, erwise ' one of [state how])
Dated .Fx�.rf�.,..... 15 '2,.{.•`" (Signed). -.. .
/J Local
This Permit is sufficient for the Removal (and Interment or Cremation) of a 'A47,p. arfy ect to local
cemetery or other regulations), unless removal is by common carrier, in which c.' . . •afisit '4.4( ) ' required.
Form VS. 61. (Rev. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of / 2/4 was A�Ste, 19
(Interment or Cremation)
( ame of emetery, Crematoorrium, etc.)
Section 7 Lot No. Grave No.
(Signed)
g (Person in Charge)
Address 4 d4
Person in charge must return this Permit to the Reg tray
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (3) DAYS with the Registrar of Dis-
trict 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 required, under penalty,
to report violations thereof.