Dudley, Isolene 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. ���
Town, Vill,�F ,,� ) �/�R�gist red No.
Dist. No. '5‘41 Count ....�.1,.a.::'r.c.'-��.t�t.� or City.,�'�'�'`., ��I=crc
(If ity, gi a str et address)
/,
same of aced .. .. !� • 4 Veteran fC�
• (If veteran, give name of War)
Single, married, widowed, /� S
Sex or divorced (write the word) .. . . .. Date of Death / 19 7.
Age. .....a!�( Y rs Mont Days Birthplace f�l..p..C�`•
Cau a of Death ... . ..,.C .. .L.c!s.... ,,.....jD�- _.. ..
64
Certificate was igned by .... ..f 7-�! , f� ..... ..... ... ,R�� �J...... - � M.D.
Address .
Place of Buria or Rem al
;If body is to b mporar in space lat it, ,l
2emetery Date of Burial „�/ d) 19 73
;If body is to he tempor rily h d, 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-
:ion, have recorded it in my Local Record with the above stated Registered N ber, and on the asis thereof I HEREBY GRANT A
PE7Tto ol-- at:Awe.blee-ine., n / ) � 7
(Nam -, (Address) �
the to hold temporarily and ... the body
(Un ertaker or son o sing charge of c se) nter, reT, or erw pose of (state how))
Dated jl` 19 ./ 3 (Signed) P
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a bad o any 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.
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 was n ,4.1. 19 73
(Interment or Cremation)
cuiIl(Name of Ce etery, Crematorium, etc.)
Section I4 I Lot No. c'7 S/f Grave No.
(Signed)
(Person in Charge)
Address 3 s .4L /U Y.
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.