Wallace, Ravaud NEW W Y OKK J I A I 1 VIYAK 1MEIN 1 yr rtniii,I ri
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ggF This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District
,(.Down 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 DURABLE BLACK INK. 3 f
// ,/ Town, Village Registered No.
Dist. Na _.,?r(?..0.I County Y L" — or City �
`�� � � /� (If city, give street address)
~� ,I , Ir. �G. Veteran
Name of deceased .. ._�...__... �'��-- 1-1-e
(If ve ran, give name of War)
Single, married, widowed, :j
,! ,!
Sex - G.� or divorced (write the word).._ Date of D 7 19 6
''
Age LL? Y s fr. onths Days , Birthplace .1Y--....
Cause of`Death..... , '-Yea- '1'2'- 'e--csf
Certificate was signed by -Wit?!... ......�' '�-r/_a. _. ._ _•. M.D,
Address e-e • -^�
•
Place of Burial or Removal). , /_d,?y�l...17a _ ...G 'L Y
(If bodyis to be to rilysyalce later) `/
Cemeery ___.......... . .... !�� . , .Date of Burial F 19 G7
(if body is to he temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, a er 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 ecord with the above stated Registered
Numbe on the basis ereo�"� Z Q-u
EREBY ,GRANT A PERMIT 14 y
to --- �c
am (Address)
the to hold temporarily and.. the body
(Undertake r pers having c arge of co se) (Inter,�r n ve, or otherwise • p e of [state how))
Dated � . 19 (0 $ (Signed) `r � ti..,.�...�.a.._. ...
Local Registr r
This Per it is s cient 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.
Form VS. 6i. (Rev, 6/63) (3A2-323)
• ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS 9R
CREMATIONS ARE MADE
Date of 1 w crwker,* was ' "\ 'S 19 4T
(Interment or Cremation)
�� rJ�avlS.�S �evKE'�tr�l
(Name of Cemetery, Crematorium,etc.)
PEGiL ig T,
Section 5 � of No. �GRTt�o�'LC-rave No.
(Signed) l e4- 4A- .
(Person in Charge) 1 I
Address
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 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.