Monroe, Henry NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
lie 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. ,,e,
5
/ Town, Village Registered No. �./ t5
Dist. No. ... 6 C/ County Zia-l1 or City ..�b - -� �-�
/� (If city, give street address)
Name of deceased /y��� [mot/ C >2(-0- .0-(2--• Veteran ..
(If veteran, give name of War)
dingle, married, widowed,
Sex or divorced (write the word) ... ........ Date of Death CA,-/ 19 7U
Age 7 at Years Months Da s Birthplace ,, a-C„(/' %�
Cause of Death t71-
Certificate was signed by (1' - ' -f M.D.
Address ,S c _ � c-4-- �?��--,---..c. -.-e � `.1`
Place of Burial (or Removal) �d'L.c.1�v t- � '.mac ,,,, .-�c�..� O
(If body is to be tempprarily held fill in space r r.... ...... .
Cemetery !Sr<<vuL .4.1.-t/..,�r Date of Burial eb /.5--r}C 19 -7O
(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 registra•
tion, have recorded it in my Lo 1 Record with the above stated Registered Numbe don the basis thereo I HEREBY GRANT A
PERMIT i
to v (/ C -e-- �3 / -// l �
.-(N�h,e) - .Sdr� )
theL'_FG1 to hold temporarily and ,.,t.. '..,. the body
(Undertaker or person having charge of corpse) (In r remove, or otherwise di ose of (state how))
Dated 67/a...3 19 7) (Signed)
Mel &at-
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a part 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) (9A2-205) •` 91
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o fr2�'!�l/ was " 197e)
(Interment or Lres3etion)
7 ° 4
(Name of r�,�} Ce Cr*71F�T8liatrt;eee, ,_.
Section Lot No. - '9Grave
(Signe
(Person in Charge)
Address /417:zvez /:ie:Ik-''-'-e--"a "�`-i
---)7-
Persocf in charge must return this erm�e Re 'stray
g l�
of his District within SEVEN (7) DAYS from above date. If o
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.