Soutter, Edith NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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.
p_giicsad No,:i
Tovm, Vill e ,
Dist. No. --5 6 a) ounty. (ja/t1.21"--/ , or City --k...p
.j
27 , A.Laat..). i7-.pteetic‘irea:/
Name of deceased cla.) Veteran city, g
Sex mtV.L..---I''74 or divorced (write the word) A--)A.e.e.,6:144/..Date of Death,„). ( -,,,2/ 19
Age 6,9 Y s
iii,,ry\er Single, married, widowed,
. /.114‘4> ths Days , • If veteran, give name of War)
Birthplace c.....0. ..,.X.,.../
-
Cause of Death ._
Certificate was signed by ' --yi :(...,- M.D.
Address xi '--7 -- _ . -)
,• ,-a,e1-..,::.=0 2, .-e.J2 )7- y
Place of Buri Removal) ,. ..Cg:I. y / '
6,
(If body is to te porarily held i 1 in space later)
40/
Cemetery ..... .. N..e._. ..A.-eQ4:t.._,M ate of Burial ' ,'''. - ) + 19 /23
(If body is t e 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 Ap 'ng to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ve re orded it in Local Record with AND
above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PE 9 7 ,
Na -C) rAd ress di
the 4.„4.z, to hold temporarily f-k-it, the body
(Under a er or person having charge of corpse) er, rem or oXisCtize of (state how))
Dated I/ - ,) Z. 19 •2 3 (Signed)
'Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body 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
Date of OW(i 1)/( ii. ` was %`ii � 19.3
(Interment os masief-)--
___f
(Name of Cemetery,
Section _ Lot No.______✓—Grave No.
(Sign 1 ik /l-` l/ i c i(
(Person in Charge)
71 _) }a 7C �j 1�-
- C 4 —L
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
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.