Loading...
Montfort, Lillian NEW TURK STATE DEPARTMENT OP HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT 0 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. 7 /, , Town, Village . Dist. No.J`�b County �/ or City If city, give street address) Name of deceased p _ - (it Veteran / (If veteran,give name of War) Single, married, wid wed,Sex . �l-1 or divorced (write the word) Date of ea 1 ? 19 rl�y / Age4 Years - Mo the Days ,Birthplace ' Cause of Death _ Certificate was signed by - -- i j / M.D. Address AS- Place of Buri: (or Removal) ___- -- -��4...Q.e...A4__-_ ---_ _ _ • (If body is to bell porarily he ill in sp e later) Cemetery__-___J_ Q, l/k„Q.4.A.) Date of Burial .2-14) 19__ __7 (If body is to .e temporarily herd, 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 registr ion, have recorded in my Local Record the above stated Regist ed Number,,and on a basis the f ERE- BY GRA A MIT ." 24(...A4 a ,.._. to (Na e) ‘ 7 (Address) the jd.• to hold temporarily and the body (Unlertaker r person havin charge of corpse) I ter, remove, or otherwi e dispose of (state how)) Dated —� r/ 19 g 7 (Signed) � A. a e istr This Permit is sufficient for the Removal (and Interment or Cremation) o 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( -e,'y' was �" ---gr 19 '7 (Interment or Cremation) (Name of Cemetery, Crematorium, etc.) Section ' -��iz: Lot No. Grave No.004,14.1( -''� (Signed) ,,,,,.... ..-81-14, 41/:;" L-4-1,--:,____-% (Person in Charge) Address/j e___,,,©1 Person in charge must return this Permit to the Registrar of his District within SEVEN (7) DAYS from above We. If no person is in charge, the FUNERAL DIRECTOR UNDERTAKER MUST SIGN ABOVE STATEMEN , write across the face of the Permit the words "No persott charge," and FILE PERMIT WITHIN THREE (3) DAVS with the Registrar of District in which cemetery is locate. SEXTONS, FUNERAL DIRECTORS and UND4- 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.