Persutti, Frederick 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, Village Registered No. -13
Dist. No. Jb0\ County. ,MC: ,-4+ N or City CC J
(� (� (If city, give street address)
Name of deceased S`,.. ... .. �.. R. T'�QT\..u. Veteran 'l\O
(If veteran, give name of War)
Single, married, widowed, S� Date of Death ) 19 '13
Sex �3sL ., or divorced (write the word) �•
Age S e.Q Years Months Days Birthplace 'NI. lti,
Cause of Death
Certificate was signed by M.D.
Address s yutArW
Place of Burial (or Removal) .... . �... .. .. r... . �..
(If body is to be temporarily held, li(f in sp ce later)
Cemetery . d _ '+4 \N.... , Date of Burial [�i 19�3
(If body is to he temporarily hel , fill in space later) 9,4j,...gt
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
PERMIT ,, t, �`
to sr�ktiAl� /v\ \� - ? . V V
(Name) _' F ressS r
the �� to hold temporarily and the body
(Undertaker or person h ving charge oof orpse) (Inter, remove, or otherwise dispose of (state how))
Dated l ..� (Signed)
oc
This Permit is sufficient for the Removal (and Interment or Cremation)of a od f to a ct to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Per t (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 ' " (- 19
(Interment or Crn-)
-)' , _ / _(/ i//,. , . /
(Name of Cemetery,t£;retnatartunr
Section Lot No. Grave No.
(Signed)
°yf (Person in Charge)
Address _ t.
)
-, 7/
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date.
person is in charge, the FUNERAL DIRECTOR or UN
TAKER MUST SIGN ABOVE STATEMENT, write across t
face of the Permit the words "No person in charge," a
FILE PERMIT WITHIN THREE (3) DAYS with the Regis
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAK
violating the law relative to the return of permits are liable
a penalty of NOT LESS THAN FIVE DOLLARS NOR MOR
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.