Wheat, Elmer Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can be signed only by the Local Registrar (Deputy er 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 CERTIFjCATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Tawir Registered No.__.-...._....._.._
Village
Dist. No- -2r. County..._ - .`ti "' : - ec-C tom.A. - —e_e,it
" /� (If city, giv tr tyLlrese)
Name of deceased , �S..i..c Veteran �(
Ingle, married, widowed, (If •`t give game of War)
Sex.. olor2/ r divorced (write the word) - Date o eath.... - * 19.‘.V
Age 7 Years — Months .......»...Days Birthplace� - • >•
Cause of Death........., �.r .. _. -f• .f .
c..,-ex..a-�:rr.et.1..� ..... . ... .
Certificate was signed by ....: �� /� M.D.
Address .3 f5.. .. . y :).:4,1,,,,_Place of Burial (or Removal)... . ...... ....6 . .c `T.l.:.(,�...
(IL body is to be to porarilp he a,�fill in space later) �
Cemetery... .�--��-� v -' Date of Burial.... --L, � �" 19L' `/
(IL body is to be temporarily held,fill in epace later)
Th4 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 accepted the same for registration, have recorded it in my Local Record with-the above stated Registered
Numbe ,And,pn Ole basis thereof. I HEREBY GRANT A PERMIT �J
to A f::44s`t, - .c. "( lS,../..t...4:1.Z.4. �i "z"" , '•.
(N ) dres
the �� -'-' to hold temp rarily and .,--
-2-- the body
(Unde ker or person having charge of corpse) .(Inter,remove,or o erwi ievoee of (et3te bowl)
Dated ,,,/.�.i. -� •4a?.ir— 19..�..;y (Signed) .... ..,�,�t.4::c. :� '
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. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE Or
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date (n was 6 6K
19
(I ferment or Cremation
✓L�--�-r`� '�%syC- \-x
�C (Name �e , Crematorium, etc.) 1
GhJ . J
Section -!? Lot No.A c- Grave No. 2,
(signed) 0-0r2i2iC
4-
(Person in charge)
Address C-'l
Person in charge trust 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-
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 OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.