Fred, Herbert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
� r� Town, Villag Registered No. 0-2V 7
Dist. No. �G' 0County Ge( or City .��-4, . €4
(If city, give street address)
Name of deceased /22 1 C -cil'Q ,o 01-i- �, Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) Date of Death% 5-72 T 1976
Age !�J Year .Months Days Birthplace �Zr-4ltt yo�«c.,
Cause of Death /'//'� ..
Certificate was signed by c-Ll M.D.
Address -21-62.-G--.---0. 0 )'2f
Place of Burial (or Removal) ...TQ— rr c c �/
(If body is to b ,7mmporarily- held, fill in space lat Cemetery .... vc e -L_-424 c-- ..��,,c.¢. Date of Burial >�/2 7 19 6
(If body is to e 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
to ... /-
(Namee) �✓( adress} r(
the .... - c_ Z- .- to hold temporarily and „__„c.,y the body
( n ertaker or ers9n having charge of corpse) (Int emove, or otherwise dis ose of (state how))
Dated f.,2.7 19 7 0 (Signed)
Lo al 4k4far
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an 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. 51. (REV. 6/89) (9A2-205)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 'L was 19 /d
(Interment or Cremation)
•
(Name of Cemetery, Cremamri uc c )
C1-1•1 eadYt‘k-'
Section . , Lot No. // 9 Grave No. /
(Signed)
(Person in Charge) 7
6-e.A-r7
Address
► Person in charge must return this Peimi 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.