Orton, Lorraine Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can ha signed only by the Local Registrar (Deputy or subregiatrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFIC,,"-E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK T own Registered No.__.1/
, Waage
Dist. No 6.. /.Cour.y. . ', .)-rit { 1 _�- ...„t, .4 k,,z,i (If c![�, give r ad dress)
Name of deceased G';i... :: :: i.X?.t.:r,.r. ...: ; (� k'd.,'74 Veteran
._1_. (If veteran, give name of War)
1 Single, married, widowed, 2 .
Sex...'., .?7.7 olor or divorced (write the word) ll. : s:Z: -- .C. Date of Death ) 7 19 ,
Age...3(a Years Months Days �% Birthplace -<3 '- K.e'[%2/ f 1 c G,!
Cause of Death -'7'3� cti,��th.L 1 I'C�4.'!`f:(+.q<t'c%"... .' :__t 1-l/'�'
b rl
ri;s.7*. J
Certificate was signed
by.. M <c-< tj Q k ° `�-i-/- .t..,..:7ji1` 'c M.D.
� ,,.{r P F.!` ^ e-,L.�+f / c 4^� J/'Address �<.e..k� :
Place of Burial (or Removal) j :7rt)7.::1.. (r 4 It .1.:c't,4 9-"-q--"
(If body is to be to o aril he�d 81 n space later) \ --eel--
Cemetery 7
.(.( .... . (4":::??'--i i,- L"`_cat-. IA: t ate of Burial ')?l�'z c; '1 19 J 7
(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
Number' and on the basla thptfeof I HEREBY GRANT A PERMIT,
to / ( 0--7)icz , j /,C-l..2 u-4 l cqt,,
r (Name) ' (Address)
the.../4 41 t 4 to hold temporarily and . ?Z`c e the body.
(I1nd taker or person having charge of corpse) •_ (Inter,remos�e,.grjotherwlse disnose of (state bowl)
/ 7
Dated....�.�.. .�.`✓..`}..�`./ 19.�?..;� (Signed) !t ‘ � tc c'_r'd ;_. ty.���
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (enbject 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was %,2,44 19
(Interment or
c w
(Name of emetery, Crematorium, etc.)
Section Lot No. _Grave No.
(Signed) Alf/ fiCA...1.,..4.) ;?
46,4„....,
(person in charge)
Address.. ;LV.,- 20.!..4./t.11,
Person in charge oust 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.