Barber, Ralph NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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. ��011� Count � v1✓t.l�-+�5� or City .•�f(lf •
city, Address)
Name of deceased le-so--6I-4-4./
"6-1/ LitA,' Veteran it/ cP—
(If veteran, give name of War)
Single, married, widowed, 7
Sex..144. g /.1 or divorced (write the word) ..... 244!l4- "' Date of Death ...._. F 19
.Age 4... Years Mon s .... . Days . Birthplace - 1 '
Cause of Death ...... . -14- �....
Certificate was saned by __,., .... ...F.cL M.D.
Address $ .G.G.�S.-�rt... . ......... ... ... .. :,o �,? ��,..> ....
PP ,. ei�..-� `
Place of Burial r Removal) ....0 � t��.-
(If body is to t poranly �q1�, (ill in space er} a
Cemetery .... ....... V.,Q, .-LA' f1 'Date of Burial )7l 19 7
(If body is to e temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated p .titulars, 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 Lo al Record with the above scat egistered Number, and o e basis thereof I HEREBY GRANT A
PERMIT 04 p y Z ��/�l//'J y��I
' ) ;;' / (Ad4are , r
the ....to
{-�i, /- to hold temporarily and ..e �iL.�:k.,� Vthe body
(Undertaker or perso having charge f cor se) (In remov , or otherwise di ose of (state how))
Dated 3U 19 . (Signed) Vial
> ;
This Permit is s fficient for the Removal (and Interment or Cremation)of a body to a part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permi S 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
Z
Date of was 197"
(Interment or GsematiQa)
/e 3
(Name of Cemetery, Cam.)
a it/«( 117:7-
Section Lot No. /7-( Grave No.
(Si ed yl L ! 71
tiz _yam/'
gn )
(Person in Charge)
Address / = 1-'4't t ,
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.