Stock, William iiimvw IVKl% aia1C YCraK11YiCi i Vr newLIl1
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. /�
Registe ed No. C
Town, Village
Dist. No. _ � 51 County d-/i/LE� or City _
If city, give street address)
Name of deceased � ��, Veteran —"mod '
(If veteran,give name of War)
Single, married,widowed, ,/Q
Sex �/�� or divorced (write the word) �-'f Date of Death ''�"`'" • 19 7 ,
Age ` ' Years - _ M nths Days Birthplaaccje� , r
Cause of Death - �- - L � - l"f ..
Certificate was signed byC _ M.D.
Address h ,
Place of Burial (or Removal) ,c.
(If body is to be porarily hpyd, fill in sp e later) �
Cemetery -(�a� 4/ c,<l`l Date of Burial_-_ Y 19 77
(If body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to e, 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 ' my Local Record with the above stated Regist Number, a on the basis thereof I HERE-
to GR�AI A R -- v. �ri Q_ISC�r� 4 7 � ,
�' ame) / (Address)
the _ to hold temporarily an the body
(Unlerta erpr erso having charge of corps (I , remo or o wis dispose of (state how))
Dated ( -L— 19 7 (Signed) te.it.e.,
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 ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of � was __ 19 7
7
(Interment or em )
A (Name of Cemetery, C -etc.)
Lel
Section Lot No. -% 'Grave No.
(Signed) ,
(Person in Charge)
Address / ik
6'
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 DIRECTORS 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 DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.