Mulcahy, Howard 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,
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.
^
Registered No.
Town, Village+ )
Dist. No. 6'\ County or City \J v-'..�� .r,,,,9rt4
(If city,, e street address)
Name of deceased ... U 1\, i(A i.Q1tit�{,',tom Veteran U
t (If veteran, give name of War)
Single, married, widowed, S
Sex ..`.6:. or divorced (write the word) ... �� Q��,M. Date of Death .... .. a1-3. 19 1
Age ars Months s Days Birthplace....L,?PS� :
Cause of Death .�,; �
Certificate was signed by -._ M.D.
Address CIA-Sc. �..i....�j„jLs� . C.�`�) V`I` �(
Place of Burial (or Removal 1-.4‘ • C2. .:Y .. 7 --
(If body is to be to orarily he d, it in space later
Cemetery C �rd`i Date of Burial < S�� 19 13
(If body is to be temporarily held, fill in space a er)
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
PER T
t0 * 1`(1/.��...n`1(A•91\""i ��' \ "x e) f\ (Address) a 1 w' \/
the W� -^� � to hold temporarily and ( A (2_ the body
Dated(Underta ror pe son'haxint charge loof corpse) ( r, remove, or otherwise dispose of (state how))
oo�� ,, (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t ny pa *of e a r 'ect to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is require .
FOItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date ofcr-r\L-ryi.—C-4* was L1d. ,-�� 19(Interment or Crematn)
,Z1 i
=•1/4;
aig 7
(Name of Cemet y, Crematorium, etc.)
it
Section C Lot No. l- Grave No. W
(Signed) Clio .a.4 . °t
(Person in Charge)
Address 2 � 1� - n� �)Oi)r4, .
1
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date., f no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across tl e'.
face of the Permit the words "No person in charge," and
FILE PERMIT WITHIN THREE (3) DAYS with the Registf
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE*3
violating the law relative to the return of permits are liable t l
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.