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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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. __
Town, Village -
Dist. No. �C1_A_____ County v-- -"N or City 'ic-a ��" c
If city, give street address)
Name of deceased----\- %,-._� c ������ Veteran
U
(If veteran,give name of War)
�� Single, married,widowed,
Sex -- `- - or divorced (write the word) `c�� Date of Death t U — [ 19 7
Age 7 a Years Months �___. Days r Birthplace ___ Si\._J_ \
Cause of Death .....�` -1'''\Se_N ..e ;`Z -- ' -s. - --
Certificate was signed by _. "'" \-- c`- -- --, M.D.
Address \\--y,_��� - --t4 - `--'- ---)
Place of Burial (or Removal) \L t t -' - --- -ti^, G—�,
(If body is to be temporar' eld, fill in space later)
Cemetery • ,-sy^..ca' z---_— cs-'l -- Date of Burial \0 l( 19 C
(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 examination,
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 Number, and on the basis thereof I HERE-
BY GRANT A PERMIT
t0 hti (Jo,. ti-L..-,_z,.T-A
( (Name) (Address)
the `i--/C' -c--- ;--' to hold temporarily and :,„s the body
(Unlertaker or person having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated 1 v - ( 19 7C (Signed) \.. ,--��—z =`---
Local Registrar
This Permit is 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) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES QN WHICH INTERMENTS
OR CREMATIONS ARE'.MADE
i
Date of 'was (! /C 19
(Interment or
(11 ..„4.„...7.r.-1..z ,
r.,_?.,..,,,
(Name of Cemetery, Cr w, ert-.)---
Section Lot No. / / 4 Grave No.
(Signed) (,./\44-4 4'--
(Per"so-n in Charge)
Address /e ' �'
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
UNDERTAKER 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 DIRECORS and UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR-MORE THAN FIFTY D LLARS FOR THE
FIRST OFFENSE. The law will be e forced. Local Regis-
trars are required, under penalty, to rep'rt violations thereof.