Warner, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
air 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.
T6 f- Registered No.
Dist. No...3552 County Oft.an,e or City p,
777
Name of deceased �N�C.[�sri1 T7. WalLyte/Z (If city, give street address)
Veteran Ye4 Wait.
MM Single, married, widowed, M (If veteran, give name of War)
Sex ('/p�e or divorced (write the word) Ala/yule
Age 5` Ye s d Date of Death,./ 6- - 19 73
r Monts Days 'rthplace /Vew g0.7i .sale
Cause of Death CCULc/1a/C Anil' �,a - Cgh,Qy7 y A ey Liea4e
Certificate was signed by WA-i.L.t..arn S. //M11On. . OejL
Address 4L . cCintt
t. e TTVe,,, m
New(bweyha N, ,, M.D
Place of Burial (or Removal) 1-.t_ne V.t.ew
(If body is tcrbe tempor i he d, (jil n space l e )
Cemetry /own O �[eey]40 �, (�j.4enn }¢ �l �/ Date of Burial 6(If bodyis to be tempo rily held, fill ins ce ater)
The CERTIFICATE OF DEATH containing the above statedng 19 ��l examination, e
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY IAS�REQUIRED nBY LAW, I have presented to eaccepted the usame for registra-
tion,
have recorded /iitt in my
Local nRecord with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT-7-
L71LO.Tt22JCsJ StYLC. �/ ,,/�,
to u (Name) 87 't `"cer� Ave Newbun h, NY 72550
the Under ahe.A.4 to hold temporarily an n(Adaress�
(Undertaker or person having charge of couple) Z` the body
Dated ,yune ><•A 19 a , remove, or o r r spo {s how))
(Signed) ..
This Permit is sufficient for the Removal (and Interment or Cremation of a bodate Local egtstra
Cremation)
the other regulations), unless removal is by common carrier, in which case a Transit ermit anyVS No of 62) strequirebje to local cemetery or
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:—/ 19 / --f
s '
(Interment or
- ----C <:: i / --- --1-4.'-4< ..-
i
(Name of C7eterfjr,4&e.ingetsuitierretc;)
Lot o. 47(4, / ) °
. -`, / .---Grave No. :—
' ,
r- /,
(Signed) (7 \ CIA1 ( t z A --7 j
(Person in,Charge)
/
Address /4.
i
— -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.