Smith, William 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,
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. `43 L
Town, Village Registered No.
Dist. No. c c0\ County l—0 i" - or City �, •? --��.
(If city, give street address)
Name of deceased ... ... ..... c,...`� Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex \\ 2� or divorced (write the word) ..'.N\c,>-)V .....Date of Death 13+. J- al....19 .1.3
Age !? Years Months Days Birthplace . _ .C.i- A.t.
Cause of Death CA \ 0t-A
Certificate was signed b -l. CQ) , M.D.
Address `p` r G..Q . GoQ ., \1'
Place of Burial (or Removal) �... . .,n� ( 'Y�:,,
(If body is t e temporarily hed, (ilf i pace att<r
Cemetery .. . .. V` sea."-:'. .. ... Date of Burial ! 1 19.13
(If body as to he 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 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 with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT ^^ ,,__--__ ((�� A i ^{� p-
t0 . ... ......j..\�ti.`^'Y. C �'- ... ...`�.i ) -A-�f'- ..t.. cq-ess} ..t.. ..
ame)
the to hold temporarily and the body
(Undertaker or n having charge of cor se) (Int emove, or otherwise di se of (state how))
Dated 3\ 19 .J..3 (Signed)
a Altar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an art of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit 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
Date of /�, l/ / < <, �as I ;I / / 197 .
(Interment or Csrrmativn)
l L 4L
(Name of C/emetery, Cremazo �-eetc.)
// /
Section Lot No. 7/ w ' G Grave No. /
/
(Signed) "
(Person in Charge)
i
I
/ ! -'-
Address % ( ). . it fi r
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 UN
TAKER MUST SIGN ABOVE STATEMENT, write acros
00,
face of the Permit the words "No person in charge," a
FILE PERMIT WITHIN THREE (3) DAYS with the Regist r
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKjS
violating the law relative to the return of permits are lia o
a penalty of NOT LESS THAN FIVE DOLLARS NOR M E
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. e
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.