Cedastrom, Lynne OFFICIAL BURIAL (OR REMOVAL) PERMIT
ILA 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
(�
/ JVill 'eDist. No. La Ci_fCpity � -2 a
f 'ty, give stre ss)
Name of deceased ___ ,e
Veteran-- - -- -
(If veteran, give name of War)
Single, married,widowed,
Sex ..d -� or divorced (write the word) - � � Dat f Death -._z' 19 '2,7
Age .6 1,,r
s __ M `/o s - D ys Birthplace __
Cause of Death' _. _
Certificate was signed y _ _._ : -_ . M.D.
Address `
•
Place of Buri r Removal) --
- - - - -
(If body is to b to orarily held, fill in s later)
Cemetery_-4 _- ,. . - _ _- ,k ,, Date of Burial — � 19._.- ,2
(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 ame appearing to be GQMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for r gistration, have recor 'd it in my Local Recor with the above s ed Registered ber and o the basis thereof I HERE-
BY RANT A PhftVIIT to
(Nay e) (Address)
t>x - . to hold temporarily and .--_ the body
e- (Unlertaker 9x,person having charge of corpse) ter, remove, o o rwise dispose tat how))
Dated -- /6. 19 - - (Signed)
Lo 1.Re is ar
This Permit is sufficient for the Removal (and Interment or Cremation of a tfody 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.
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of�� l H% as 9 7 7
(Interment or Cremation)
(Name of Cemetery, 6r,gmatorium, etc.)
J
ef/
<'ote Grave No.
Section of No. ✓,
(Signed)
(Person In Charge)
>327 Address C / .
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.