Alden, Shirley NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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.
Town, Vill_E.,
1,,stered o. 7,5
Dist. No.-.<0.07-c'/ unty Zei A...rv.jey ., or City
Name of ceased . ... ' / a-z Of ci%give street ads
Veteran 7(6)
(If veteran, give name of War)
Sing , married, widowed,
Sex or divorced(write the word) . Ci.,7 z.4/1Z-e Date of Dea /7",— 19.9.,
Age
e Yeilipeztie.„ ,4tIonps Birthplace
Cause of Death
M.D.
Certificate was signeAby_
Address Place ).7-...)-
of Buri r 6 Renral T.
(If body is to e emp.p_rart y e d, i 1 in spac yit )
Cemetery ..,,./.,..6 •,(1-L1--
Date of Burial //—<7)6 19 23•
(If body is to he temporarily e d, fil rie.,i5n space ater)
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, have recorded it in my Local Record 'ith the above stated Registered Num r, and on the basis thereof I HEREBY GRANT A
P E R hp-T)
t%'4e-.&
to /
., ( a ress)
the to hold temporarily d the body
(Un ertaker 9r persmptitving charge of cor!...1) ter, renzli or Arf:riskofe of (state how))
Dated 7/--- c:A.2 19 / (Signed)
Locr ,Regigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a bod 0 any part of ti. 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 -y/yLC/1./ ' was
(Interment or Cl en-4n)
)
(Name of Cemetery CtemaFa3+trm, sec
Section -2 Lot No. c'`, - Grave No.
(Signed) �,,1 �U << ;_"
(Person in Charge)
Address ` Z. j /' 1 �.� (
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.