Denton, Percy NEW YORK STATE DEPARTMENT OF HEALTH
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, LEGI LY WRITTEN IN DURABLE BLACK INK.
R stered No.
Town, ' erge• OP
Dist. No. .( Cou •
_ (If city, give,-- eet addres CONam of deceased �� 2 c \)ft ,(rto,A( 1 Veteran - r w<
4 (If vetera. give name of War)
Single, married, widowed, /
Sex �..... or divorced (write the word) . . ... .......... -..Date of Ih ... .3.. ..�.... 1912
Age - aiii,_ rs o Days Birthplace ..
Cause of•Death..
Certificate was signed byA. _ ��` r M.D.�/} M
Address '.. a,r�v`e„ . W 4.il E:aa,?` —
Place of Bu V (or a oval)... Ord%
(If body is to be • poraril eld, fi in p e :ter' �)
Cemetery . ._ + 0 ' Date of Burial .1 —..-1.— 147./f/
(If body is to •- temporarily h fill in space later)
The Certificate of De 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 sam for regi on, have recorded it in my Local •cord with th- i. .ve stated Registered
Nub r, and on th si thereof REB GRAN A PERMIT r '
to --- .._.... .a Ii 2-3 . -' ' t
1Address>
the to hold temp. . and I the body
Und a er r per n having harge of co e) (Inter,re• 1150. oth is- .ispose of [state .w
Dated. . .. 19 (Signed) - f
Local Registrar
This Permit s sufficient for the Removal and Interment or Cremation) olk 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, 82) 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
r--
��� 7
Date of ,h. ' wa
-
� _.19_ t, 7
(Interment or Cre tion)
(Name. emetery, Crematorium, etc.) 7
Section T,ot No. Grave No.
(Signed) /' / Ce cz_
/�� L--l-��z
(Person in Charge)
t / t.
Address G - ' _
Person in charge must return this Permit to the Registra( '
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.