Mellon, Beatrice NEW TURK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
Town, Village
Dist. No. /e./ Cou or City
If city, g. e street address)
Name of deceased • /F.-a-il.0-14.., Veteran "---------'
(If veteran,give name of War)
Sex
Single, married,widowed, 404.4.e:fe4
....ktia or divorced (write the wor Date of th 57 r 19 .4r.
,-•Yeapea.4.4....atrt .D irthpl ce
Cause of heath
Age
Certificate was signed by il: 4 3-;44 M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily h f* in space 1 '
Cemetery Date of Burial S.-. /2" 19_V
(If body is to be temporarily d, fill in space later)
The CERTIFICATE OF D ATH 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 registration, have rec ded it my ocal Rec rd w' the above stated Registered Numb , and on the sis thereof I HERE-
BY GRANT ERMIT
( am • (Address)
li the to hold temporarily and the body
(Unlertaker or person having charge of corpse)
5
Dated 19.76P (Signed) .
-: 7
Local Registrar 4fe,04,
This Permit is sufficient for the Removal (and Interment or Cremation) of a 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) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of r-wr,*•2�r was 2A-0-y 1 -- 19 TY
(Interment or Cremation)
n �11Jru%y`
(Name of C etery, Crematorium, etc.)
Section -s Lot No.6-- 5/ Grave No. --�
(Signed) er---7: -sue
(Person in Charge)
Address � e ez� ct f r`'
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.