St Clair, Frank 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.
Town, Village\kit},,,) e •ste d N
--n
Dist. No.,.., ..`1 0 t4 County or City
(If cit\Cestreet address)
•
Name of deceased .76..ek:::-L1,-,--1)1/4ar ...AN.t . a, Veteran
(If veteran, give name of War)
Single, married, widowed, -
Sex ).,---( t or divorced(write the word)
of Deek th 112 19 '7-3
Age ck\ .Years .Months Days Birthplace AlkA.4./Cause of of Death \A„lt--Z.e•,-- ' .0.,A,1"--
Certificate was signed by M.D.
Address \S-0 , V..t.,A..,. 1?-&elAc_. \AA
Place of Burial (or Removal
(If body is t b temp r y h d,.ii n space at )
Cemetery Date of Burial
(If body is o e temporarily Id, fill in space ater) /0 - / 7 19 7,3
The CERTIFICATE OF DEA 1i containing the above stated partic ars, 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•
tioi have recorded • •n my Loca Record with the above stated Reg tere Number, a the basis th of I HER BY GRANT A
PE T c---\-•"- ,.,
• -
(A ress
to \LC‘
CP-4i
\ - 77kr___(Name.)
the to hold tempora ' d the bo
(Un ert(FklIr o erson1h11,1"ag charge of coPys-9) (Inter, remov o o hert d•spo (state how))
Dated
'kJ. • ••• ••• •••• (Signed) , . . .... . .. ....
ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body a art f the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit V . 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
mom.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of tv+` was _'c ti 17 19 73
(Interment or Cremation)
(Name of Ce etery, Crematorium, etc.)
Section A E Lot No. `/ Grave No. 6
(Signed)
erson in Charge)
Address 3'C Jf' J pi)
LL a I
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
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.