Wesson, Anna 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.
Tone Registered No.
Dist. No, -�D-/ County.... or City
of ci give street address)
\Tame of deceased...c.r�le�� ,.---- • Veteran
(If veteran, give name of War)
y Single, married, widowed, ,,p�1
Se r or divorced (write the word) Date of D -leecr ..r�,19. ..�
Age -7 Years. Mo hs... D s Birthplace
Cause of- ath
11)4,_
Certificate was signed ... ... ' -._. M.D.
al
Address... elk—- . ... .. ....
Place of Burial (or Re val) `' �/��
(If body is to be temporarily fill in
Cemetery < Date of Burial 2 1 19.7
(If body is to be temporarily held, fill in spac ater) ,/
The Certificate of Death contai ing the above stated particulars, having been presented to me, after careful exami-
nation,.the ame appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have a `ted the same for re istration, ave recorded it in my Local R cor wit the ove s egistered
Numb ••d o. the basis then I E GRANT A to
C e� /�
(N ) (Addy --
the ,,r xtA .���1, to hold temporarily and .., t e o,1�'-
(Under or person having charge of core ) ��I {Inter ove, oth dispos of [ to w])
Dated - ,2 9 19. ' (Signed) .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State 4i.ibject 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 of (94,7Xatt was 19 G 7
(Interment-wme ant r)
j71- ��e'���(Nam oP Cemetery,@emwl�l�e,) U
Section �— Tot No. /G Grave
(Signed)
(Person in Charge)
Address LPLfr
✓4i �l
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.