Francis, Blake NEW YORK STATE DEPARTME!
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Pr iary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT ANt. COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. e ,
/ Town, Vill ¢�,� RGK tereNo. ..,
Dist. No.�IJ 6/ nt c. or City �9 -'�•- ..F:. . ? su
city, tt'e eet a ress)
a)Name of deceased
(If Veteran
(If veteran, give name of War)
. Single, married, widowed,
Sex or divorced (write the word) . .....a/vtAzeiDate of Death„,../ /�` 190-
Age r Months Day Birth ce.. .. C/
Cause of Death .. .L .. � ..
M.D.
Certificate was signed b ,/
Address 3. M.D.
Place of Buri. o Removal
;If body is to .e te• •orarily he , ill in space a� r of Burial
�emetery ...... _. :. Z}.......... D ate if"?' 19.2,2
;If body is to e temporarily h ill 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-
:ion, have recorded it in my Local Record wit the above stated Registered umber and on th asis thereof I HEREBY GRANT A
PERMI �j
to . .
. . • ...Tradres s
ame
the ` ��/J to hold temporarily and the body
(Undertaker or persopp ha g charge of corpse) ter, remove, or otherwrsg dispose of (state how))
Dated /l— 19 3 (Signed) Zi.Li 7i1*eltif T -.
This Permit is sufficient for the Removal (and Interment or Cremation)of a bod any 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
I2 �y,
Date ot� '�� � was 19 /'
(Interment or C-remm en-)
(Name of Cemetery,te� Cxetuatorium, etc.)
/ &/(/ 7
am- -/( //C;Ir�i /
y,
Section . -21' Lot No. �� Grave No. ' -
,—(-- r. ,/, ,
(Signed)
/ \) _-
' (Person in Charge)
i
( ' < ��i. / -''C.
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
.1 FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
4 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.