Evans, Albert INGV• IVRR JIMIC Locr-mn I mcn I gar P7CAL1rl
OFFICIAL BURIAL (OR REMOVAL) PERMIT
a 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.
Town, Village 1
Dist. No. ,L'_ County or City /,f w
If city, give street address)
Name of deceased e- •-1--.--) Veteran 121---
(If veteran,give name of War)
4 Single, married,widowed, �19._Z '
Sex or divorced (write the word) aR , Date of Death
Age arsMonths Days Bithplace / 1-
Cause of Death -- ``' 0 y `
Certificate was signed by __ oz . ..e-4_, M.D.
Address �r4,'--- _-'
Place of Burial (or Removal) 7 , 7
(If body is porarily held, fill,in sp e later) y-,
Cemetery _ •-tA- v ' Date of Burial"9 � ' 5 1924
(If body is to be mporarily 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-
BYo A PERMIT n ?ilo /�- ®�
- (Name) ELT/. (Addre,$)�/ Q $e y
the ' erg�zryti �€ to hold temporaril _ the lroly
(Unl r r ors gersonhaving cha a of corpse) ( ter, move, or q er se dispose tate��ow) \
Dated � �" .-f 19_ e (Signed) `' j - C"�") _
Local Registrar f
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject toC ocal
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) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of ll'' /1 i was " '` ' 19 7r
(Interment or GixematipnL_--
(Name of Cemetery, L rem orium,
/ etc.)
Section Lot No. //7 Grave No.
17-4 a' A-)2
(Signed) ,
(Person in Charge)
/e4'
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.