Johnston, Willis NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rgr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilrage, 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 Registered No.
Dist. No.S� a/ County w O(A.A. ) or City aA.ti add
/ A ' � � /�� � (If city, give street address)
Name of deceased a)...N 15 15 V eran
(If veteran, give name of War)
Single, married, wi wed,
Sex t p or divorced (write the word) Date of Death 7/36 197Z-
Age 3.2--............Years MrAj.ths Days Birthplace
Cause of Death
Certificate was signed by a - .. M.D.
Address ,
Place of Burial (o - -moval �(fl4. g�>
(If body is to be t p• arily he� , fill in space tat f
Cemetery .... ,q � Date of Burial �j .� 19 7Z.
(If body is to be temporarily el , tl to space later)
The CERTIFICATE OF DEATH containing the above stated parti Lars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTO Y AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have .corded it in my L•cal Record with the above stated R istered Number, and on the
basisa thereof I HEREBY GRANT A
PERMI V / L� /` � , ,)
to r//i r �,�s i r�� y ,
r ( ress) 1
the - - / i // to hold temporarily and IV the body
(Undertakererson having h9.tge of c r se o
) (Inter, ve, or otherwise dispose of (state how))
Dated .. 19 (Signed) .
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any p oft State ject to ocal cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS- o. 62) is required.
FORM Vs. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 'th,.z was u 1 197- ,
(Interment or C ctiee)_____
(Name of Cemetery, c.)
?f214 de/4 2 f
Section / Lot No. 7j7Grave No.
Si ed `' r / ,Z it
( )�/ (Person in Charge)
Address - t/ C_
Person in charge must return this Permit to the Regi/trar
of his District within SEVEN (1) 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.