Campbell, Patricia NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ear 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.
Town, Village Registered No. 5 ,
Dist. No...t�‘�/ ty ���, or City a -74-E6
/) �% �/ (If city, give street address)
Name of deceased r -fir �- (--, yr. ... (.� Veteran
(If veteran, give name of War)
Single, married, widowed, T
Sex / i,,m.Q� or divorced (write the word) . 4 *:K:-�Cr- Date of Dea Gd'6T •�L, 1910
Age , ..fv...............Y ars Months pays Birthplace ' 7. ..
Cause of Death :e-..t.s.:.(.x.F 2. 1:47t,� soma.
Certificate was signed by -- ,�• �_.,-44 M.D.
Address s: azi,„, <G- �j �
Place of Buri Removal) 7,e./.1Y�_s._. .,.
(If body is to t porarily he d,_fill in 5.pace ater)
Cemetery ...,rG.—• Ux<c t,t./ (.." .xr�-t,1- Date of Burial 0 c;,�. / .19!741
(If body is to a 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 Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT (1./
a�) --"S:it..e-� � (Address)
the to hold temporarily an4-� the body
(Undertaker orlper on having,/charge of corpse) (Inter, remov o other se dispose of (state how))
Dated &t. / / 19 .76 (Signed '� 49 /9 `
L cal gistrar
This Permit is sufficient for the Removal (and Interment or Cremation) a b to any part of th State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a ransit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (9A2-206) 91
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o was � " / '
(Irnterment or C'srefflacica.)..,,, ,.
(Name of ,Cemetery, Ceri4
tl
Section Lot No. / Grave No. /
.4y)i
(Sign '
(Person in Charge)
Address_____P
Per in charge must return t is Permit to the istrar
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.