Harppinger, Donald nib W IVKA JIAIt VIIAKIIV1CINI yr t1tALlri
OFFICIAL BURIAL (OR REMOVAL) PERMIT
iSF 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
No. 20
Dist. No. .. County.... -- ..a. « or City -
1 / (If city, give street ad less)
Name of deceased. .- .. .. Veteran tat/..J/.(.7:=
SeX..__..... dt..�irS.� Sior gle,divorced ( (If veteran, give name of War)
Single, married, widowed,
(write the word) Date of - eath..-/.a..- -- 19.y
Age ' / Years-.. Months Days Birthplace.
Cause of-Death
Certificate was s' ned by . .. . - 4.44. M.D,
Addresses a -7
Place of BuriaL,(or Removal)-_., .ac�f�'
(If body is to b to orarily held fli] in spice t - q y[
Cemetery_.-•. --,• .. -- � .. _.,., Date of Burial---�.f�^ l` 19 6,
(If body is to be temporarily held, MI in space later)
The Certificate of Death containing the above staled particulars, having been presented to me, after careful exami-
nation,.the same appearing to he COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Reco with the ov-`tated i egistered
Numb , and on the"is reof I H BY AN PERMIT ivl �� /fc„
to
(N �
the 1- / to hold tempo and LI(Addres,
the boK
(Undertaker or Berson having charge of corpse) (Inter,,remov�or, - ise dispose of [stet 1 ow])
Dated....I..Q — /a" 19.L:.4 (Signed).•• - . - '
,41. fory/ ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b, t. any part of the State (subject to local.
cemetery or other regulations), unless removal is by common carrier, in which ca e 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 qR
CREMATIONS ARE MADE
Date o `—was /7 19
(Interment or Cremation)
rea--ehl (`•( e of Cemetery, Crematorium, etc.)
Section_ 2 '- '1a.r Lot No. 7s Grave Na:—
(Signed) _ ' C! '-� `—�� 1� j�i
(Person in Charge)
Address _e
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.
it