Willard, Nicholas NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I" 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No. `t'3 i..
Dist. No. ..b-C, 6 k County ‘(..CA •••4,-..-1t..... or City -'b--"-a...- - -,.s-,.,•, .,-
(If city, give street address)
....Name of deceased '.. D \(!(,....,9--&...e-,, p` Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) ... _ Date of Death cl-h'a - 191v
Age 4- o Years Months. Days Birthplace kiN• t
Cause of Death �R--v:..� ��=-4 ,_..� V
Certificate was signed by .... k.,--M(.�- _ . ° ,t.,-- -- -v,,, ) M.D.
Address cr „„.. . Q%-..-Q--
Place of Burial (or Removal)- _,fill
_„
N
(If body is to be temporarily' held, fill in space 1 er)
Cemetery `��--,,,,,,_, `L n,'„,,_ .p— Cam, Date of Burial - 19 19.61
(If body is to be temporarily held, fill in space later) t
The CERTIFICATE OF DEATH containing the above star particulars, having been presented to me, after careful examination, the
same a,ppearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
to (330- --,... ` r--,-- 13 (f 444„— ,
(Name) (Address)
the- --�1=-- -- to hold temporarily ands, the body
(Undertaker!or person having charge of corpse) (Inter, r move, or of rwlse dispose of (state how))
Dated
lI 19 (Signed) d /ll s r
This Permit is sufficient for the Removal (and Interment or Cremation)of a bod to any part of th Sta (su • ct to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is r quire
FORM VS. 61. (REV. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of '144(��Ai' wasSCA 19
(Interment
(Name of Cemetery,+ Cttl¢ea'tutium,
47,7„afiP4i
Section Lot No. j #trave No.
(Signed)
(Person in Charge)
Address
>Person in charge must return this Perrlt to the gistrar
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 District 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.