Dickinson, Mary NEW YORK 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. L f j
(e}/ Village
Registered No.
Dist. No. �� County Town,or City ._ ___ __
If city, give street address)
•� /Name of deceased / 4—cam j v' , Veteran
(If veteran,giv name of War)
Q, Ingle, married,widowed, /'
Se. 4_,,,,, — - or divorced (write the word) w���� Date o Dj eath /Z 19
Age 72 Years Mont s _ __ Days Birthplace /
Cause of Death `t /
Certificate was signed by M.D.
Address %. .24-16
Place of Burial or Removal)
(If body is to be t orarily held, fill in.spa 1 ter)
Cemetery )17 ' ">.
Date of Burial /F 19--.t
(If body is to be emporarily held, fill in space ater)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the s. e appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I ave accepted the same
for r&_ ration, have rec rde it in my Local Record :f w.th the above stated Registered Number`, d on t asis they I DER
BY r• •NT A PER �-� , / 7
to /C4 c
•ddress)
Id
th� /n.-�e) to hold temporarily and --.-i off.i. the body
(Unlertaker or person ving charge of corpse) (Inter, r: 4.: or . erwise /. f (state how))
Dated /4. 19-7e. (Signed) / Local •egistrar
This Permit is suf icient for the Removal (and Interment or Cremation) of a bo.y to any part of t e 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 .(44" was Oi�/� 19 77
(Internment or Cremation)
-6E�L., o :----(----e-Oi/--
(Name of Cemetery, orium, etc.)
Section //.ilL- Lot . (-,Grave No.
(Signed)
(-- (Person in Charge)
LL-iiel
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 perso' s
charge," and FILE PERMIT WITHIN THREE (3) D "
with the Registrar of District in which cemetery is locat,t,
SEXTONS, FUNERAL DIRECTORS and UND;r'
TAKERS violating the law relative to the return of per ' 0
are liable to a penalty of NOT LESS THAN FIVE D
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.