Wilson, John NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
;Sr 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./,0 �, /a- ''`� Town, Village �f/J-� �_ ��.
Dist. No. G Country, ,(/�/JJ(� I� or City W�
_ fV �- f 1 mil!/ ` If city, give street address)
Name of deceased C ' _.-.__.. Qn Veteran
(If veteran, give name of War)
,.y� Single,married,widowed, /
Sex / or divorced (write the word) q/l/L,.f .L�f.-:. Date of Death -Y- 19---.
Age 76 , Years M nths _- Days Birthplace .r //////
Cause of Death / a.. .... .
Certificate was signed by M.D.
Address t- -e,-
Place of Burial (or Removal) __..toto .-C t.-. a '
(If body is to be emporari hel �i in spade �r)/J
Cemetery Q.,'- • _...�/-%„t:.L Date of Burial `.S/D 19-2
(If body is to be temporarily held, fill in space later) JJ
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 registration,\ have recorded it in my Local Record with
the aove stated Registered Number, and on
the basii thereof I HERE-
BY GRANT..l.-L '.l�� `' 4.4k.l^-�.�'� ---7\ ‘ `7 i� o`"_ x� iCS -?e--�, ,�ctiG�-
( ame) ` (Address)
the to to hold temporarily and the body
(Unlertaker or 'having charge of corpse) (Inter, e r therwi of (state how))
Dated 19..7X (Signed)
Local Registr
This Permit s sufficient for the Removal (and Interment or Cremation) of a dy 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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address
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 1oc -r.
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.