Burrows, Matilda NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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.
Dist. No. �'«` County G" �'�+v�x�V- or City tom-= g--01-
1 (If city, give street address)
Name of deceased ) ) �..ft. i . &-et... a1..., 1„•,-,--4,7 , eteran
(If veteran, give name of War)
Single, married, widowed,
Sex `i � caL
or divorced (write the word) `-Y.k1.Gl.,V14.x.we.t Date of Death .., —7 i �� 9 ..76
Age arse nths Days Birthplace +�..',,.I• L' l
Cause of Death
Certificate was signed by . 11:2. K_jJ;L c. •, M.D.
Address 9-,. .. �R .ems.-+ ..
Place of Burial (or Removal)_ �. in.u-t. o L ..-w � -, I V/�
(If body is to be te�, gq�arily held, fill In space later) n ...
Cemetery L..J_�:3.� % is,elie Date of Burial ' lam' 19 70
(If body is to be to orarily held, till 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, hay !recorded it in my Local Record with the above stated Registered Number, and and
o�n�the
basis hereof I HEREBY GRANT A
to PERMIT 1:Lit v`' `P r� �7 u"""� U ,
( m_e) Address
the :t.ei..n.F;Q,Q.k„. i::t ,A,!12' to hold temporarily and ,,,,1 ,,,, the bo
(Undertaker or pers n having charge of cords ) (Inter, ove, or rwis spo of (state how))
Dated i 1 19 ....L (Signed)
Local'Registrar
This Permit is suf dent for the Removal (and Interment or Cremation)of a body to any rt 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) (9A2-208) •7 �-•8 -
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o79jVi A 17--e-tr1.r was 19712
(Interment or -
alzi,
(Name
/fofff Cemetery, C
Section , Lot No. /7Z rave No.
(Si
(Person in Charge)
Address l�-1—E—
le/
Pe on in charge must return this Permit ( the Re strar
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.