Tillerington, Davis 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.
Registered No. -1�
Town, Village �Q_
Dist. No. �5 0/ Ztnty �/1ALIA or City >21 k (�""J-
/� /� If city, give street address)
Name of deceased -�' w , �) _ Ca-'h Veteran
(If veteran give name of War)
Single, married,widowed,
Sex or divorced (write the word) �1 - Date of Death / /5( 19,-
Age ? Years __ __ Mont s ays Birthplace 27 r -
Cause of Death - -- ---- ------ ---'-----
71,--4-
Certificate was signed by _.________ _ _ -e M.D.
Address 7z)_ ,k. 1
Place of Burial (or emoval) ,:.C: 2 �7 p4,
(If body is to be tempo ly held�,�i)t �in�s �.c�later)
'Cemetery . T1�:x�L(1 Date of Burial / 7 19_z
(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 same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I ha a accepted the same
for registration, ve recorded it i my Local Recor the above stated Registered Number, d on the asis thereof I HERE-
BY GRANT A R l�//
to /36 /'
( e) r (Address)
the to hold temporarily and ___fir .._ __ _6( the body
(Unlertake or pe son aving charge of corpse) (Inter, -.•• e, .r therwis:J.is of (state how))
Dated / 7 19..:21 (Signed)
' v. :4,- : s
This Permit is sufficient for the Removal (and Interment or Cremation) of a r' to any part of a 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 '�K�L"�e as y 19 77'
(Interment or
(Name of Cemetery,
tad f2
Section Lot No. -r 1/4s--f Grave No.
/52 Ctil.,z
(Signed) i �
(Person in Charge)
/ l&-Z�% e
Address yi/
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 STATEMEN
write across the face of the Permit the words "No"person
charge," and FILE PERMIT WITHIN THREE (3) DAY
with the Registrar of District in which cemetery is locat
SEXTONS, FUNERAL DIRECTORS and UND
TAKERS violating the law relative to the return of perm :."
are liable to a penalty of NOT LESS THAN FIVE DOE
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.