Clother, Lida NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Yin-age, 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. 7 //]
Town, lla a RDe(�stered No.
Dist. No�6c( 7,9ounty � J or Ci
(If city .g'ive(scree address)
Name of ceaseZ,Z,2.a.:
d ` ... 6 �. Veteran �J/ d
-- (If veteran, give name of War)
Single, married, widowed, /
Sex .. ��. or divorced (write th word) W... Date of Death I ( 19 73
Ag Years /Months 5i..^Days Birthplace
Cause of Death x.-e'-,... _ JL
Certificate was signed by '-1-4�. �y.. M.D.
Address ��i ' .. .. ..:_... .. oc(C j "
Place of Buri Removal ,. } ., r���
',warily body is to ',warily byy di, (i -in space vper
Cemetery .. .:..:G.y - C.tie--c?../ c3 Date of Burial f 19 ',
(If body is t e temporarily held, fill in space later)
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-
ti ,,,
on, ve recorded it in my Local Record •ith the above stated Re stered N ber, and on the basis thereof I HEREBY GRANT A
PE
a./(Name) (.,„,,...
/(3Kddress
the . c-C� to hold temporarily and �ti the body
( ndert�r person having charge of corpse) (I remove or otherwise dispose of (state how))
Da
ted — 6?- 2 19 .-7�.. (Signed) ..
LOCal a tr
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y 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.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
y
Date of ""v ) i'z' /�/t was______________J 19/
(Interment or- e' )
(Name of Cemetery, etc.)
/( 7LL4 , .1.-' /
Section _-� Lot No. ` '' ''' Grave No.
(Sig i_ei7,) Z <C_ y.�
' (Person in Charge)
A 7� L
Address L/' • C" �{ ---
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 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.