Dixon, Mabel Form VS.!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tT 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 CERTIFICAVE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. �s.
' row,---,- Re tered No.—..f
Village
Dist. Nock 0 i County... ri /t,
....:v Y`r�h or City S
M ( (If city, give street addre s)
Name of deceased �� I Y v ti Veteran �o
Sex �� , A/ Single, married, widowed, (If v to . give name of War)
Color Vv or divorced (wnte the word) WI CloIA'Lj— Date of Efnth �- ��"" ,4 19 41
Age Ye rs Mon Days Bi place l.0 �'l�,
Cause of Death �Y �, j 'crr�f.V...Jl�ite,Jcr.f-- {Ji S.�.r.e..�. ..�-
Certificate was signed b ... Y.42 (..t hi cK M.D.
Address f y....ii,� L. 5 ,, l- l c,,e /4.71_,
Place of Burial (or Removal)
(If body is to be to orarily help,Au in space later) /i
Cemetery /' h V V cw C-- Y/ cr— Date of Burial fi--.Zin d'J,1 19
(If body is to be temporarily held,f111 in space later)
The 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 registr tion, have recorded it in my Local Record with the above stated egistered
Number-and on the b ' tli f ER BY GRANT A PERMI�
to .1aA, )....... .. . .,' / )S V`uY�✓`1 �.. ./.., Irp,J 11-5
rr // t,� ) `(Address)
the 11�ij f f 1 to hold temporarily and l h c✓ the body.
(Upder)ake or p_ersoa having charg of gorpse) (Inter,re ♦ ,or otherwise-dispose of[state howl)
Dated.....FF!!-- i---T d r, 19.> 'T (Signed) � �-, .......tkR ner4,4S
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (ea port to locil
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 OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date f ., was •
• �`v 19
(Interment or C ration)
9 - i
• a --.... --(.., i _...._
(Name of Cemetery, Crematorium, etc.) j
Section Lot No.r.3-C—Grave No.--""--
4
(Signed)- ., -�. ..--�6D2G f -
(Person in charge)
Address L 1 -`--&
Person in charge oust 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.