Nullerton, Rhonald •-- / y 70
Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir This Permit tan 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........). 7
...., _ VillageDist.
Dist. No. 1.i.5-.:1 C,ounty.....a,)..a.1--1-vp-t or City ....e.e....„e.„,e.A-.-Z
..)
l''' (If city,give str address)
iiiZ--Name of deceased. , VZ-'t' --'4---6,
c-h-eeZ-
• P-27/ Veteran 4.?034yits?(A-A.- .. .
v Single, married, widowed, (if eteran. give.
Sek4.1a...Color.a.. ...or divorced (wnte the word) •"1'7 Date of Death 7‘? - ---6'name of War)
194.2
Age 40 Years ' Mon A,...).--...D ys Birthplacit:::: 7
Cause of Deathf.:22 - 4.41-2
Certificate was signed by..„..d.S-:::....,-,..,:e.- . . - • ,,,..,-..--‘‘-r----(- ---‘.-7:‹4:-?,..ii M.D.
--
&W.:,... .-2 0--e-,-
Place of Burial (or emoval) /
(If body Is to be temporarily held,till in space later) (
Cemetery Date of BurialV,Zee..--e--- 2.--? 19,./. .?
(If body Is to be temporarily held,fill in space later)
The 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
Numb ,,and on the basis thereof I HE1EBY GRANT A PERMIT
to la.Z.V.‘‘' crX..,C" . .e,/,72‘,4--/iiirzei.e17 , ..
me) 7(Address)
the '-/ , i.• ':( et.,1 to hold temporarily7,,,i t-.4..-"1.f. ..C'er^ the body.
ndertak r verso having charge of„corpse) nter,remove,orth,eesWlle dispose of[state bowl)
Datec14/ 2-'3? 19.ji./7 (Signed)
v-'' /ez al egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) a. y to any 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.
ENDORSEMENT OF SEX1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date 3 was �Z319�
(Interment or Cremat )
emeto
(Masse or Cemetery, Crematorium, e .)
cress/
Section Lot No �5= Grave No. 3
(Signed)/%21 Z,-,-..
(Person in charge)47
f�!
Address / Th44
Person in charge mast 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.