Surprenant, Doris NC1111 WICK JIAIC NCPAKIMCNI VI' IltALiM
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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. q
Registered No. 0/ )
Town, Village - �J ,
Dist. No:-2 County..�U.G �.� _ or City _ Vi(. ��� t a
�(�-- , Ay
If city, give street address)
Name of deceased✓Fes, ( ,x.__ Veteran
(If veteran, give name of War)
, t
e ,L oSingle, ma ied,widowe ,Segel 1 "' or divorced (write the word) , _ ___ __. Date of Death /2- 2 ( 19_7
Age Year/2_- Months i
Day Birthplace L-c.1
Cause of Death _a_____ ____ ___ _ -
Certificate was signedy M.D.
Address ` , /
•
Place of Burial (or Remov ) ,A.t. b.-1---"-7
(If body is to bete orarily he , ill in space I er)
Cemetery /_/'_. 4,--yn-6 Date of Burial ` '7 19.7.7
(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
t0 on the b 's thereof I HERE-
BY GR PERMIT
for regis a ion, have recorded it in my Local Recordwith the above stated/Registere Number, an
, g.,2,s„.. J/6
444_ "N� (Address)theto hold temporarily and __ a nV the body
(Unlertaker r person having charge of corps ) (Inter, move, o erwise os (st ))
Dated_ __/. _.�h 19 _ (Signed) _
•
Local gistra
This Pe mit is sufficient for the Removal (and Interment or Cremation) of a body to any art 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
4 Date of was21'J "4-/ 19 . .7'
(Interment or gr.--( i :1;1:) -1611/iltie '')" "6'.--"L-
-
(Name of Cemetery,-ele...atormm_, etc.)
Section Lot No. Grave No. ..
(Signed) `'(
(Person in Charge)
ii4')'
Address ti ,`- ,/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 THIE^ (3; DAYS
with the Registrar of District in which cemetery is 1 d.
SEXTONS, FUNERAL DIRECTORS and UNI -
TAKERS violating the law relative to the return of pernl s
are liable to a penalty of NOT LESS THAN FIVE
LARS NOR MORE THAN FIFTY DOLLARS FOR 4
E
FIRST OFFENSE. The law will be enforced. Local lie
is-
trars are required, under penalty, to report violations the f.