Graham, Isaac 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,
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. a‘7
(iteogile4d 7
Dist. No..S6 0( County. (1....) t......„7 To , Villa
, Veteran(If cltY: -- c
ive sire addftiss)
veteran, give name of War)
(If
Name of deceased k,Y,.. .0c1(.....--• , br.z..)
Sex . .. )- Single, arried, widowed, A , j _ ,,
or divorced (write the word) 4:-.6,--titie. Date of Death ' —7 4 e3
Age i Year ---._..--- Mo the .,35 , Birthplace ,...."---c•-c-'(7
Cause of Death
Certificate was signed by c krel, a2 2 _40 - „4--avr. M.D.
Address
Place of Buria teo oRrearmpyve71)d 72---i C.J ..e.44,a7k-44-1.6
(If body is to II I , ,114.iii- ce later
Cemetery ......./....4/Kit,„ ,4.41.-r..1 Date of Burial Or-' 5 193".-Z
(If body is Wile 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-
tion, hay ecorded it in my Local Record w'th the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMI
to
aaciress)
the to hold temporarily and the body
(Uri ce;ta err_pe.7on Ming charge of c24p,v) (In remove of (state how))
Dated 19 7.....J (Signed) /II,
Local Registrar
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
Date of 4' IC 5:- 19 /
(Interment or Cie " )
- A y
(Name of Cr/ter/, Crefrracornm-it_s_a_:,
y
Section Lot No.A:;?'6-.7rave No.
(Signed); -(' ( 4 4
(Person in Charge)
NJ
Address
- e
Person in charge must return this Permit to the Registrar
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.