Davignion, Clifford lNICW YUK& J1A1I IJCPAK1MCLY1 Ur 1-1CAL111.
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 DURABLE BLACK INK.
Town, Village Re istered No. //6
Dist. No. '„(6.(.._ County iif_.GC .! or City
Y, (If city, give street address)
Name of deceased "�1 .. Veteran
(If veteran, giveve/name of War)
le, married, widowed,
Sex.. + or d divorced (write the word) G?7 Date of Death. ,.h.. 19.�/
Age .1„ Years. Months. Davy r?,r+,,,;tacP sate,-
Cause of-Death
i
Certificate was signed b _, - - M.D.
Address _G ,@..P
Place of Burial (or Removal) _ ,✓�7 ..el. K
(If body is to be temporarily held, fill in space or)
Cemetery z�/ Date of Bwria ___Alt,(/ _ 9' 19...6/
(If body is to he temporarily held, fill In ace later)
The Certificate of Death containing the a ove 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 Recor ith the above stated Registered
Number, and on th basis thereof Ii RGRANT A PERMIT
t "
to
(N e) dd ss)
the to hold temporarily and the body
(Undertaker person having charge of core e�)/ (In remove,or otbe wise dispose of 1st to howl)
Dated 'V 19.6.,f.4 (Signed) ..
Local 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, 8 2) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS 9R
CREMATIONS ARE MADE
Date of 4----1: 4. �-was 9 194
(Interment or Crematio
ilLri
(Nam of Cemetery, Crematorium, etc.)
Section I�w. Lot No. € ?1 Grave No.—L_
(Signed) -- _____
ee
(Person in Charge)
Address d 6
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.