Jabitz, Edwin Flew TVKK 3 I A I C DCYAKI MCP.I car MCALIM
OFFICIAL BURIAL (OR REMOVAL) PERMIT
E' 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. l
//'' � �� j �Q, Re i tered No.
Dist. Now �; / County A., ��'Lx�— or City
VillageRC ''�" 1� �
If city, give street address)
Name of deceased__ G ...c."--e- 1 4 Veteran •
(If veteran, give name of War)
Single, married,widowed,
Sex - C�e- or divorced (write the word) 1 '1,4-4.) - Date Death A Z1---,,2_J-- 19. a
Age 'Id Ye Month _ ` Days Birthplace
Cause of Death c/Lli
Certificate was signed by . /1
`' L M.D.
Address 7 ,cc,t,i_—,,: i \� c�l�•-.,
Place of Burial or Removal) CI__ -- _ ,
(If body is to be t rarity held, f'1 n spa 1later) • �j ��
Cemetery ,,Z...,ni 1c. - Date of Burial__.CLlJ-Zi .; f 19,2
(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 re • ation, have recorded it in my Loc 1 Record with the above stated Registered Number, and on he basis J(L
f I HERE-
BY G ' PER n (�[ (
Q (Name
� ) (Address)
the "�//�C't '/ to hold temporarily and the body
(Unlert r or person having charge of corpse) (Inter, re e, or wis of (state how))
Dated ' a 7 19--7C. po(Signed)
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body o 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 ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of� = 4�'lLLat/� was '**`r/-2--%19 7
(Interment or G;rean
al;-'e 17:(---e/ger
(Name of Cemetery, lkematorium Ate.)
Section Lot No. i •C 7 Grave No.
(Signed)
(Person in Charge)
---_.7-, .....,,, . 4
Address "
/
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 STATE ,
write across the face of the Permit the words "No per n
charge," and FILE PERMIT WITHIN THREE (3) DA
i.
with the Registrar of District in which cemetery is locat .
It
SEXTONS, FUNERAL DIRECTORS and UNI
TAKERS violating the law relative to the return of per,, s
are liable to a penalty of NOT LESS THAN FIVE -
LARS NOR MORE THAN FIFTY DOLLARS FOR T'A
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.