Ashley, Ivas NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
r' 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 Regied/�o.
Dist. No. �S G 0/ County alez-- yam?"2, or City J G -,"-v
(If city, give street address)
Name of deceased , ��'`- .fit.-i a' ..-z% Veteran -e •
(If veteran, give name of War)
Single, married, widowed,
Sex � -4a 6 or divorced (write the word) � ::c:Lt,-ed� Date of Death ...j7 - S- 197C
Age q Years ...Months Days Birthplace
Cause of Death /7�- G%r
Certificate was signe y Cut-}' - M.D.
Address �"./:�.>...�`'���-,
Place of Burial (or Remo : �„ „fir ea..
(If body is to be tmporar e•d, tf 1 1 s ce to
Cemetery - _:- --' <.. ' =..1 Date of Burial „(./ ' i 19 20
(If body is to he tempora ily 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 r corded it in my Local Record with the above stated Registered Num r, and on the basis thereof I HEREBY GRANT A
PERMIT �f / B
to '�r��"� .�-cay, / 'F `- 6 -C . _.G-y✓J C
.. Gt+ e)az
ddr s.�
the to hold temporarily and ti„r o the body
(Undertaker or person having charge of corpse) t (Inter, rem re, or otherwise dispose of (state how))
Dated `J % 19 ,2 (Signed) - G,61:s.- �t.�--
Local gist r
This Permit is sufficient for the Removal (and Interment or Cremation)of body o any part of the Stabject 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) Q
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date oft ' " r �-4 was l 19��
(Interment
(Name of Cemetery, Cr ,
Section Lot No. ve No.
(Signed
(Person in Charge)
��
Address
•
erson in charge must return this Permit to the Registr r
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.