Harris, Flossie 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,
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, Village."--) Registered No.
Dist. No. %,f County �'�n��`or City
(If city, give street address)
Name of deceased y • ` 0—S..t;...ig ./ `' k` "(.-7tir /Veteran
(If veteran, ive name of War)
J Single, married, widowed,
Sex / - —a .--,r or divorced (write the word);'.'`''%Coy Date of Death,,_ // f 19 --'
Age U .- Years Months . Days Birthplace... i
Cause of Death 4 ..,,
Certificate was signed by �` .... ..--...J M.D.
Address G - ,,,,,,,i,
Place of Burial (or Removal) �?�--kci 4 � 4�� L'
(If body is to be temporarily held, (ill in space later)
Cemetery .. ' , ;...(:.rr..'C Q� Date of Burial 7l ) 197
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particula , 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-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT '
(Na ) / c --J C.C�et (Ak G ../ _ i
re s
the -G.-.. ( to hold temporarily and ✓ / the body
(Undertaker or persoyhavi charge of cop ) (Inter I move, or otherw se di se of (state how))
Dated %(..,/ 19 .7 (Signed) `�f {/ _/ " R is par'
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to anart 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
Date of L L { , was / /,s— 19
(Interment or Cc a ian).
� —
(Name of Cemetery, C )
/''<<e-(-7 /. .
�
Section — ) Lot No. u Grave No.
t /1, k
(Signed) •
(Person in Charge)
A /
Address----
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 UNDERTAK S
violating the law relative to the return of permits are Ha o
a penalty of NOT LESS THAN FIVE DOLLARS NOR M E
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. e
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.