O'Brien, James NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rair 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. 3
/,' II Town, Village Registered No.
Dist. No. O I County C6).4.4 cr r./ a
or City i
(If city, give street address)
Name of deceased eteran (If veteran, give name of War)
Single, married, widowed,
Sex 774-4,L _ or divorced (write the word) Date of Death ,17-( p 19
Age � Years.( 7-/S'
.S '/( Months Days Birthplace )7. �D.
Cause of Death J ?s ..`,.c�k,,a ��
Certificate was signed by 1-k1/ ‘!/.h..i., c�`� M.D.
Address ` /
Place of Burial (or Removal) .. h ......
(If body is to be mporari)y held ill in spa l er)
Cemetery V. a,... .J.. Date of Burial /� -i7-773 19
(If body is to be temporarily held, fill in sp ce later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented-to me, after careful examination, the
same kppearing 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
to -/ (Na e) �� Adaress}
the to hold temporarily an ..Ll,i - the body
(Undertaker or person having charge of corpse) (Int r, re ve, or otherwise dispose of (state how))
Dated /'-17 19 y? ‘ (Signed) 1 ...7.1.ls..C�,�v
Locr..Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of ti.e 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.
F'OItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
E � �6Cr yZ�as � �_ �'�� � 19 Date of " 7=
(Interment or Csemtion4-
t) (' !' �E`�<--
(Name of CemeteryrCrematorium, etc,-),
Section Lot No. Grave No.
(Sired) fi L ( /\ ( ) l �t
(Person in Charge)
/L .��
Address L
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) 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
TNAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.