Harris, Sherry nc.n iut[K 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,
tillage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. .. r,.
ReIle
I f Town, Village stere o. ...s„3-/�
list. No. Q County ( or City
(If city, give street address)
'ame of decease SrLt--o' Veteran
(If vetera , give name of War)
Q ogle, married, widowed, s
ex 44:zi• �x +�.iz_ . or divorced (write the word) 1 ��- Date of Death �/ 197
ge ! Years , Months - D Birthplace
ause of Death cr , ' +w - •
2....rgteareon.
7
ertificate was signed by ... ( ... G.. .:.... M.D.
Address Q...e1�... ........ ... � ,
lace of Burial (or moval)
f body is to he tem aril • held, tR s ac r) ` / /
emetery } ) 1 Date of Burial /� �6 19 7
body is to he tern oraril el fill to la
ter)
p y d, space
ie CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
me appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra•
in, have orded it in my Local Record with the above stated Registered Number, d on the b is there f I HEREBY G A.'T A
ERMIT
CA-Ltt---"...Y .23/44,--4---Lt '
( me),� / / Address5
e a.4.i \
r � to hold temporarily ands the body
(Undertaker r pe73so havy•ig charge of cor ) (Inter, re ove, or oth wise pose of (state how))
ited // .../..tl 19 ..7, ' (Signed)
Local Registr // ��+'
This-Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State ('ubject to(IoFa c teryor
ter regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required. �`.�
)RM Vs. 61. fREV• 6/63S 13A2-323)
ENDORSEMENT OF SEXTON Vti eEttbuN uv nrtmuE.
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
G� Lfzti�'Date of was /G /t 19 8
(Interment or Cremation)--
(Name of Cemetery, Gr6matorium,
� r1
1 ' ' C t
* R Lot . c.
Sect0 Grave No.
Si ed � i�L'/1-If
)
(Person in Charge)
Address -- 4
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 UNDER-
TAKER 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 UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.