Rushford, Armond NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gam' 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, Vi lag Regi tered '� O
Dist. No.
s 0 ( ounty L��I�C- or City / y.k� y ..r....� )
(If cit give scree address)
Name of deceased .. . ... ....... ..... �`"'L Veteran Cy
(If veteran, give name of War)
Single, married, widowed, C".—
Sex / or divorced (write the word) .. 23
. .. Date of Dea 19 .
Age....Li' rs... M the s Birthplace...
Cause of Bath ... 2rY/Z ... .. .... ; ..
Certificate was signed by ... M.D.
Address '... ...-�`C - .. '-
2
Place of Buria Removal�� : , ..,.�(„�1�. -..
(If body is to t porarily h�Eld) tin sp e er)
Cemetery ... .. ..-,i1�lrt�. Date of Burial ��, 19
(If body Is to 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 Appe.ring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav/recorded it in my Local Record-wii the abo stated Registered Number and on the basis thereof I HEREBY GRANT A
PERMIT. /r — (Zi ' '` L%
to .... f.G �2..) . tat... � r..l. ~1� .....ce s s / y
i (Name) > '✓ .
the / to hold temporarily an ... the body
. .(Under[. person Xing charge of c se Int remove,ircheryr di ose of (state how))
Dated / 19 (Signed)
rir cal glifirar
This '/rmit is sufficient 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 Permit(VS No. 62) is required.
FOdItM 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 fir ; �,� .; ` was \� t .,( 19_
(Interment •-' .,nt
(Name of Cemetery, Crematari�aar-eis.)
Ai _ I
i ,(.' ---i t" (✓,' "'.'i ,
Section '`Lot No. 7 l-°/ Grave No. '-----
(
(Signed)
(Person in Charge)
i
Address J —
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.