Nevens, Fenwick lNGw I% MR 3IRIC YCrmcimmI VP' HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
il 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.2 2``I
Dist. No. S 1 1 County Wii, 1 or City -sue
��C:' If city, give street address)
Name of deceased A' ' Veteran ye--• f h
(If veteran, give name of War)
Single, married,widowed,
Sex _._1[J�e or divorced (write the word) .. __ Date of Death ___,S_ Z177 19 1
Age ?Ss Year Months Days Birthplace ___-A r -
Cause of Death //-Fe —
Certificate was signed by , .-�� M.D.
Address .3,7 7- fl e �e�� —
Place of Burial (or Removal) ry 1 y
(If body is to be temporarily held, fill spa e ate
'Cemetery t. r__ _L .2 Date of Burial A 192 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
for regist on, have recorded it•'n my Local Record with the above stated Regis red Number, and on the basis thereof I HERE-
BY GRA ERMIT .-
tO 6dZie;12.---- ic--&-G--
- _(N� (Address)
the to hold temporarily an the body
(Unlertakerpr person having charge of corpse) ( r,jmornr
of�wIise/jispose of (state how))
Dated - ! 19..7 2 (Signed) • !'hc�. xzt.
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
Ilir
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ORM 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 ` ` 'i`1 1 was >i' 7 19 77
(Interment or Cremation) a.
1?,- (-4
(Name of Cemetery, Grlttta-teriuw,-
Section ot No. Grave No.
(Signed)
(..)447-/YI
(Person 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 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.