Tucker, Ada NEW YORK STATE DEPARTMENT OF HEALTH
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 Registered No.
�
Dist. No. La./ County �. .. or City 11
04--)2-01--•
(If city, give stregksddress)
Name of deceased .. Veteran s i C`
(If veteran, give name of War)
-Single, married, wiElewed,
Sex.`— or ftiv d-(write the word) Z4J-+....Date of eath.. ... j..3.0 19 6 6
Age 4471-- Y rs,. `-— Months ---t Days / Birth lace
Cause of-Death.� > L .-• .
Certificate was si ned b ... ..e.. .a .............. ,.1:?z.., M..D,
Address... -.. ,\t'e .:,... . .. . .. ... v
P_
Plac of Burial (or Removal).. ,.�, ... -r. cz--'-'--2.1 ., _- y
(If t is to be temporarily held, fill in s later) j
Cemetery Date of Burial ( :19.. ..`.
(If body is to be temporarily held, fill 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 registration, have recorded it in my Local Record with the above stated Registered
Ni.; ber, and on the 's thereof I HEREBY G ANT A PERMITIj
to: `'t'C 4' "�l�•/t `r' �__ ./-!<t7....1.!-x *,CW.. ,v9y
(N ) O
the .`. ':.... � ..._. to hold tempo 'ly and the ody
Y..l.
(Undert er person having charge of corpse)p (Inter,remove,or Qtherwi dispose of [state howl)
Dated .... .. .. I 19.62.5 (Signed) c- �`
Local Reg' aar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod o any part of the' tate (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a ansit Permit (VS No, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS C)R
CREMATIONS ARE MADE
Date of-o^j2 2L was 2—"19 6�
(Interment or C aho
(c.°.;J
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave
(Signed)/2LZt
(Person in Charge)
! e , 4./
Address L( 7G /./x i
f111✓
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 1'IVE 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.