Beaty, Florence Nh W Y UKK J 1 A 1 C 1JCYAK 1 IV.C1N4 1 'Jr ricti.a.,i ri
OFFICIAL BURIAL (OR REMOVAL) PERMIT
igr 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. p�
„
� � Town, Village Registers t3aZ
Dist. No. 4f 1.... County Y":,1.,.�i tbil ..r or City
C rr (If city, give street address)
Name of deceased....�.�°'. . ... .... ,� Veteran
(If veteran, give name of War)
�` Single, married, widowed,
Sex...0 ...., or divorced (write the word)....✓`,��'h Date of Death.... 7 19.C.
Age.7 fYears. Months Days Birthplace .e.:4 .4..�
Y
Cause of-Death �. � ��
Certificate was signed by 4.-,.. .deh.• :.f:tfrfi,...._.� M.D.
Address ,,,..Z
Place of Burial (or Removal) n
(If body is to be temporaril Id, Il in a a I r) //
Cemetery ...Lr �L€, �� ! ., Date of Burial4r.47 19.6
Of body is to be temporarily held, Sit to space ater)
The Certificate of Death containing the above stated particulars, having been presented o 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, recorded it in my Local Record with the above stated Registered
Number AVe b thereof I HERE GRANT A PERMIT 1:yy pD
(Name) •►; .
the _ to hold temporarily and �F the body
(U aker pars ..having charge of co se)' (Int .remove,or of w dispose of Est to w))
Dated .4..7 19. ,Y (Signed)
4 , Local Registrar
This P mit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Sta a (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) is required.
Form VS. 61. (Rev, 6/83) (3A2•323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
-;new
Date ofs��—�f;=t0 �j-- j was 19
(Interment or Cre Lion)
o ,
f V t ) -y C.stoi
c XI ( Z
.0
? . 1 (Name of Cemetery,Crematorium; ete.) 1
,ti
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t '� �' Section T,0 1 t—�
,/ N� � � Grave No.
tP `jr c" S.c(Signea �`4/Hi � �1 .
r�. .. • (Person in Charge)
Cz" ti ,e ,d3z,--_
Address
t.
�4 , ._-,1 ,9-
F..t f.. PersonrifI c arge 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-
lc
* 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.
—1
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.