Beswick, Delbert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar 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. '.-- .LATown, Village Registered No.
Dist. No. - " .1, County „,?,YQ-N . or City C� Nt--
(If city, give street address)
Name of deceased ` .: Q fa. ‘ Veteran ,4�"J. J`� \••
(If veteran, give name of War)
Single, married, widowed, J
Sex 1 C� or divorced (write the word) .:''�i1�tiNs-� Date of Death ..I ... ... k. 19 ....Z.'1...
Age -1,3 Years Monthss, Days Birthplace
Cause of Death .. 'S C:.+s -a,-`N'--C'4 ?-�y.s .
Certificate was signed by .... , .. - ... tl. � M.D.
Address s55- \ti
Place of Burial (or Removal
(If body is to b emporarily held, 1ili ins ce later
Cemetery -`ice.. . tisa .) a ..` Date of Burial 319 M
(If body is to he emporarily 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,n, T
,(hhave recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
P \
to v-N'--en S�, �,.••-Y , \ �.3\5 ---k- CUl),.. U.�,.� C Cr'LSi
'� -K--, ? y�^
Name) (Aar/iess
the --Al'Y\ .,.\..t,. '-c-` to hold temporarily and LS2. `. the body
(Undert ker or person having charge of core) ( , remove, or otherwise cl pose of (state how))
Dated i 19 .`/ (Signed) 1
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y part o the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Per (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
/ G r..
Date of `' 'z TI `. ,,. was t.z � , 19 /��
(Interment or Cr. *t.op) /
(Name of Cemetery, Cremarorrum etc.)
t
1c I( ( ai ,i 1, )-Ir
Section - �'•-'' Lot No. . / 4" Grave No. ems.\).
(Signed)
(Person in Charge)
Address / 7 "—;<. / 4 �/ -
4. ) /,_ , , .ij -LI
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date I
person is in charge, the FUNERAL DIRECTOR or UN
TAKER MUST SIGN ABOVE STATEMENT, write across t
face of the Permit the words "No person in charge," a
FILE PERMIT WITHIN THREE (3) DAYS with the Regic
of District in which cemetery is located. �„,y
r
1
SEXTONS, FUNERAL DIRECTORS and UNDERTA S
violating the law relative to the return of permits are liab
a penalty of NOT LESS THAN FIVE DOLLARS NOR MO
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.