Alkes, Morris Ntrr PORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rgr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
'illage, 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.
Town, Village Register N
5 // l g
)ist. M C)/ County �L/ �� or City .
v (If city, give street address)
Lame of deceased Veteran
(If vetera , give name of War)
0,6t-
Single, married, widowed, /� ��,ex or divorced (write the word) (ram Date of Death -../ 19 .•►ge Ye s .. Days Birthplace �[ -.K.. '
:ause of Deathp � � '�'�`
:ertificate was signed by17. M.D.
Address ,....... '
'lace of Bur' 1 (or Removal) �1lw� ' %� lz:_rIf body is to a to porarily he d, .
emetery .... . � Date of Burial V Y 7� 19..,',..�/.
f body is to e t mporarily , fil in s,,'e later)
he CERTIFICATE OF TH containing the above stated particulars, having been presented to me, after careful examination, the
ame appea . g to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
on, have orded it in • ocal Record with t e oye stated Registered Number, and on the basis th of I H Y GRAM A
ERMIT '
(NamlS .... (Andress
1e to hold temporarily and .. the body
. . .:.. ...
( ndertaker o pers n aviq, cftarge of corpse) o e, o o er tse dispose of (state how))
ated , Y ]/ .19 77 (Signed) f.•.
Loc Regi rar
This•Permit is suffi lent for the Removal (and Interment or Cremation)of a body to any part o he Sta (su(eC7Ptelocal cemetery or
Cher regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is req ited.
ORM VS- 61. (REV. 6/63) 13A2-323)
ENDORSEMENT OF SEXTON UK rzxaUrr uv L.rte+rcvr.
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of !/ /7 was 19
(Interment or Cremation)
4aft r-4 e- f;14.
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address /3( ertrek J '-
° 5 i /f ly
Y
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.