Smith, Frank NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
�.�` 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.
J/ J Town, Village Re •stered No. rl
Dist. No. �/ County w or City
��
Name of deceased ��%ffyS Veteran(If city, give street address)
(If veteran, give name of War)
Sex Singe,vo ced married, widowed, /6" Date of Death . .....,.3/7� 19 75
or vorced (write the word) W
Age ..T Years' ppoo � .Months . ay Birthplace ' y,
Cause of Death t� c
Certificate was signed by , .. ... y, M.D.
Address 2 .art-:h d/-
Place of Burial (or Removal .(JZ.cl7�! ._.C..4P-, U
(If body is to Iae; ,mporari 1 in spac at
Cemetery (.C/ Date of Burial 3 / -2 19 .73
(If body is to he temporarily h , fill in space later) /
The CERTIFICATE OF DE H 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 r iiorded it in my Local Record with the above
stated Registered
edd�Nummbb r, and on the basis� � thereof I
HEREBY GRANT A
PERMIT � -L tl )21,1_,frc a_L-2"`-i. ,- ':`" 7L! �%S :( z.4. „ )o ,.� > cnaa ss
the / to hold t4nporarily and �is the body
(Undertaker or son aving charge of corpse) (Inter, r ve, r otherwise dispose of (state how))
Dated a(.) 19 7 .3 (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any pa of t%1I. !rocisi .ate (subject to local cemetery or
other regulations), unless removal is by common corrier, in which case a Transit Permit(VS o. 62) is required.
FO41M 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 i1- 'mil'� 121-\was o1/44 ' 19 X3
(Interment or trema-tion)
(Name of Cemetery, .)
Section Lot No. Grave No.
ri
���" ,�
(Signed) •
(Person in Charge)
Address 1
/ r
Person in charge must return this Permit to tli egistrar
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.