Statdmann, Lena NEW Y( `STATE.DEPARTMENT OF HEALTH
OFFICIAL_.BURIAL_. (OR' REMOVAL) PERMIT
"This,Permit.can be signed.bnkl;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 CER-
TIFICATE OF-DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK., Registered No
Town, Village AA
Dist. No.,_6-�'r1 Count_}t}: , or City -i'''''' r t'.- : ,....y ,
.Qmay` /
�l (If sit give street address)
Name'of ddce>ssed:i....t�' - �!/A 1'J _- Veteran le
(If veteran, give.name of War)
•Sitigpniarried,'widowed),
Sex- `G or ditiorced (write the tivord):l.- u"`el Date of Death..171.l.,l,/. 7 2 19
Age. Pi Ys rss bidnth Days- Birthplace,, 6
Cause of;Dathl: .., �,nt4 %`` p?"Leer -t:....
Certifieate,wag%i ed liy _-_Gr :c3—*--��. c-&_.--' /21') M.D.
Addliesss. _
Place of Burial l(or Removal) Ees- , ; .r-cam:
(If body is ta.b porarily`held,+fill in space-datati r)
�
Cemetery. -� 1 Date of Burial 7�� 7�" 19
(if body is to ademporarily'-hefd,,fitt in spacedatetd:
The Certificate^of Death",containing=zthle. above-stated`particulars., hiving been presented to me, after-careful exami-
nation, 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
Numl} ,ands at_:basis eo HEREBY GRANT-A PERMIT �w�
to , L � i`c 6f_S�
1% 4CJ�I (Address)
�'}l , `-
the.._. ter hol(Etemporar. y and_l e-1-, the body
�/(/y[J'7/��at ,or person tilting chargpw£korpse) ter, remove,or: erwise disp a of tate ,
Dated.15Y24..J...,7 199 (Signed). ., y
/�// Local.!Registrar
s Permittis,anffireienttfor the-Rkmoval (ar a Interment'or;Cremati'on)of a body to any part of the ate (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) (3A2-'323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date o was__ G 4/ C-- --2./_19__ _
(Interment or,crem.tiattr
_... 4.....----yr__ V ...re—en--0‹:"---
(Name of Cemetery, C.natsrieun,.,eLC,L__
Section/l4L�e7J Lot No. y!" Grave No.--_
(Signed) _
(Person in Charge)
(I -
itt / /rev:5, '67,c-
Address
1
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 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 Dis-
trict 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.