Haydell, Robert 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 ;ER,TIF�jCATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. J 5 //l
Tiso-vv1-l.age egistered No.
Dist. No. /L Count}, or City
/ (If city, giv scree[ address)
Name of deceased ii' A ' J & 'G C---Veteran
R217
Single, married, widowed, , give name of War)
_ u -- or divorced (write the word)
20
................Date of Death 19
Age Years .Months Days ` i place... �
Cause of Death klec,<-e,L....:'� ` ' C�Q2L
Certificate was signed by a.-C .f', ")-_-.e_c -Li4.� 1� M.D.
Address ..., , .k'_- i"-z`.c_-e�c.. ; '� — _
Place of Burial (or Re oval) �C.L -y G i�-e/ �F-� ;
(If body is to he tem or it • he d 1 to space:l r ,ry r
Cemetery p y , p(�) -{__. Date of Burial --�` J 19 a
(If body is to he temporarily held, fill in space 1 r)
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 /ecorded it ip my Loca7Reco'rd with the above ated Registered Number, and on the basis-thee of I HEREBY GRANT A
/I)
PERMIT //
(.f l a °`LC.•,2x c2�GC-L-s.a....� 'vLC- . /,i �22 '"6"`t..- �'.'`�-1'� `C
t0 -,
' - ,(Name) ;' j ` (Address) `
the -C'� • 4[-,/f1.6'Ko'I�c�'temporarily and „[-2- ---1 the body
Dated(Undertaker — rson having argeloof grp�se) Inter, remove, of rw[so,disp2s+�of (state how))
l LJ (Signed) —4- -�
ocal Registrar
This Permit is suffici nt for the Removal (and Interment or Cremation)of a body to any part of the State (subj(t 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) )3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 6- f,2ryn g-J was Ctiep/4.17 19 7('
(Interment or Cremati )
(Name of Cemet6ry, Crematorium, etc.)
Section ce Q Lot No. 3 3 Grave No. a
(Signed) 6fed: 4''t-'`G(Person in Charge) a me,.1 sec. )
j Q�J„
Address 3 5 ) 4& �//�"G:,�-29 !V Y
Person in charge must return this Permit to 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 WI-THIintiREE (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.