Viele, Vivian rota TURK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
'illage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
lEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. J
,5-� ' ���„,"�'� Town, Villa r. R ster No. /
)ist. No. p ' County ... a�Y"�ti/.C". - or City �/J..... -
O (If city, give s reet adres.ame of ceased ... .,,0,/. /v•.i (L, tL2_ Veteran .....E,,�
(If veteran, give name of War)
Single, married, widowed, �j � � �� // /� `)
ex _., or divorced (write the word) ./t,,.�1'..,w.G''S' Date of Death /! — hi— 19
ge-. ,>.. Ye s nth ry Dray Birthplace
7 y
a e of each ........... . .
ertificate was signed by ... �/ .... M.D.
Address
lace of Buri• 1 (or Rem al� ys . .. .... ..
� body is ro e temporari h f l n pa,�ce(,,{at�er)
..meter 1'� "" 1_f r . ate of Buriald 19,-
body e tempor 1 y eld it in space a er) //-
1e CERTIFICATE OF DEAT containing the above stated particulars, having been presented to me, after careful examination, the
me appearing to be COMPL E, CORRECT, AND SATISFACTORY AS • QUIRED BY LAW, I have accepted the same for registra-
in, h ve recorded it • my al Itec rd with the above stated RegisCP-d Number, and on the sis thereof I HEREBY GRANT A
ERN ,
1 / Cri
me 9 (/ jress?
e 4 to hold temporarily and „•. the body
g ndertaker or person havin charge of corpse) (Inter move, or o erwis ispo a /state how))
)red .. 1/ — , { 19 ...2 1 (Signed) T. � ' „ex.,-
Local Regis rar/
This.Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (. Iect to local cemetery or
ter regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
>RM VS. 61. )REV. 6/63) 13A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHANCiL
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of t was i' / 19 7b
(Interment or Cremation)
, r
(Name gf Cemetery, Crematorium, etc.)?
Section Lot No. <" Grave No.
(Signed) ( - - --
(Per on ni Charge)
Address A d �lL
/3'4 xl'r . 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 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 District 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.