Madison, Mae Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or Tbh Permit eau 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 Registered No.__{.., ... ..
Village
Dist. No.. County--... . ..fir.., or City ,
(It city,give street address)
Name of deceased •
��� �� — ,l.�s�c'� Veteran
Single, married, widowed, t(f veteran, give name of Wax)
Sex Color y or divorced (write the word) �l" f.Date of Death ' 19 S"
Age ‘.Years Months ;: Days Birthplace ,::;l4. r .4....' 4 sl• 4
j
Cause of Death • -. ......k� try.. F ?- '4--`,/.�.:s.i.
Certificate was signed b}�'�'` ,:?` „� M.D.
Address : ,:......lj. •,
Place of Burial (or Removal) i }.-/-
..c4.6- : ")/ 9
(If body is to be temporarily held,fill in space later) _,
J
Cemetery "- a--6 �:, Date of Burial 6../.Z.:.j 19.
(If body is to be temporarily held,fill in space later)
Thq Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis the I HEREBY GRANT A PERMIT
L
—'(l�itae (Address)
the >%r "�',G-' , to hold temporarily and.... . . . . the body.
(Undertaker or pe a having charge of corpse) (I ,re ye erwise oose of(state how))
Dated S Z d 19 S4 (Signed) . . .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any peat of the State (subject to local
cemetery or oilier regulations), unless removal is by common carrier, in which case a Transit-Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE C-6.77,4—
Date 2,7,/,,,,.,...„3/
was - .7 19 ,
(Interment or
/_Z.: !IV,').2 ': .
r//;Z2 ' . ',2 7
""7"2 _
(Name of Cemetery, Crematorium, a c.
Lam-
Section Lot No. Grave No.
y- / f
/(Signed) / >GI._- n �..s�7G t!' '1r
(Person in oh ge)
Address 'P u .��2 di
4
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re-
quired, under penalty, to report violations thereof.