Stark, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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. /f 6 C
Town, Village
Registered No
Dist. No. 3294 County 0I0EIDA or City MARCY
(If city, give street address)
Name of deceased 1,1> I (1 t s, n Y' k. Veteran no
Single, married, widowed, (I�f/�eteran, give name of War)
Sex male white or divorced (write the word) widowed Date of Death --`-C— 19 CS- ,
Age .$ Y rs. 8i- Months - 2- Days, r Misso
Cause of-Death.- ��.n�.c.v t,c-= 1..)2_42‘1%._•thpla
eL l. 4,: 2e,.f) �.�,/
r'l)
Certificate was signed by P M.D.
Address JIR c .,(�fk..b !4 '/-p J(R�c )Ui. L .
-.-
Place of Burial (or Removal) - sg,4.2:yti. .1.�.tc,4%...
(If body is to be,porarily helfiy411 in space later)
Cemetery..... . ..._ . Date of B "ial 19 C-J
(If body is to he temporarily held, fill in space later) f
The Certificate of Death containing the above stated particulars, having been presented to e, 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 Re istered
Nu ber, and on the basis, J ereof I ER BY GRANT A PERMIT
to . . n ----t.A._24...1,4 . . .u..c c. ..e <!5s n.�J.... .�.t.�X�� 'lea
+me) ,�]dress)
the 2 .. a-- to hold temporar' y and czSY�CGs./ the body
( n ertaker or persm2. living charge of corpse) (Inter,re ovel Qtherw' e of [state howl)
Dated ...c,hL^ 19.a.. (Signed) 4.,- -�
Local Re istrar
This Permit ' 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.
Form VS. 61. (Rev. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date was G 19 C 5�. -) (Interment or
) ,,," . 1 /72
f(N m of Cemetery, Crematorium, etc.)
/CCIrl— eae-e"----
Section / Lot No. Grave No.—_L_
(Signed) a 6?Z", -
(Person in Charge)
Address ‘F ` }� -
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.