Pierce, Peter NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
li 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. ._3 7
WATewn, Village/ /Dist. No. 1(oJ ounty_.._ rr- ' or City .e a.
If city, g'v street address)
Name of deceased Pc, it.r ! C rt 0— Veteran IE
(If veteran,give name of War)
AA Single, married,widowed, �^, �7 y
Sex FYI�`�t- or divorced (write the word) __�?_i_PI.;We— Date of Death __.7./i !�l-._ 19
Age 3 Y Years Months Days Birthplace
Cause of Death
Certificate was signed by M.D.
Address �'`
Place of Burial (or Removal 7Qkrb •a4 .A*
1?� .14gA94*
(If body is to be tempvariilly held, 1 n space lat )
'CemeteryI j2L Gw L.�n ..Ar.-iii Date of Burial-_] It/• 19
(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 have accepted the same
for registration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY GRA A RMI
to -- f �.ti-�, az erd i e e, I3C 4✓v - sf 4k - k/i 't>'
� ) (Name) (Address)
the L(.h-. t t4 .- - to hold temporarily and / 4 2✓ the body
(Unlerta r ng charge of corpse) , rem ve, or o erwis dispose of (state how))
Dated 19 (Signed) -
ea i rhr
This Permit is sufficient for the Removal (and Interment or Crematio a body to any Art 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 We-A---0---c-j9was 4 / go 71
(Interment or 6reri3 _ t
(Name of Cemetery, Cwr.tnrimn, etc.)
7}4 (0
Section e 3i Lot No. _ V Grave No. / '
(Signed) ei4-1-1/
(Person in Charge)
ram / / ,,��
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 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.