Rourke, Lena NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar 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, Village Registered No.
Dist. No. S6 County I-t/a [�� or City a
(If city, give street address)
Name of deceased 64, ---- A-�-- Veteran
(If veteran, give name of War)
Single, married, widowed, • �
Sex or divorced (write the word) ...,fti~L��A''-T7" Date of Death / 7-73 19
Age 79 Years /-/s'y� Months Days Birthplace
n
Cause of each t n,� le--61-
Certificate was signed by .. 4 . /(/yr,., M.D.
Address ru�4.....4
Place of Burial (or Remo 1) kkt
(If body is to be temporarily d, (i lj in spa �F)
Cemetery }-,%rc.c. -fir/.-..... ....UA4:.a/ Date of Burial /-c7-//-73 19
(If body is 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 he above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMI
to �� wit c��P.... Ux hy
J (Na e) / (Adaress)
the G ,.,�, to hold temporaril and t the body
(Undertaker or person hav�ge of cor se) ter remove-, or otherw a dispose of (state how))
Dated /,?-io 19 .7_ (Signed) 0�c�.....M.
Locr.Regigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t..= 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 �szt r` `} was 19 / ''
(Interment or CtPfiiairob)
(Name of Cemetery,Deem t nnf etc.)
rt
Section ��"�� Lot No. G "ve No.
�,'�� '( '
` L" i
(Signed) :
( • (Person in Charge)
Address 7,1 / /t i_ ✓�—
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.