Russell, Bert s=rm os.aL 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 CERTIFI�,C�AtE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No.�%...
Village
Dist. No .6 .L..County..lz cL or City ,,.4.--
_ (If city, lve street address)
Name of deceased --� , 2,� f�—� v Veteran
Single, married, widowed, r (If veteran. give name of War) _
Sex' ', '" 'Color. C,� or divorced (write the word).., .2..L.�--'�--(-' Date of Dea -.. ) ` 9-2 d
�y1
Age / Years Months ..Days 'rthplace t..:.. .: 2• ( i.:.i/ '1 1,.
,--- /-
Cause of Death ti: ..... .. �[
Certificate was signed y . ,? - f .: .. .. M.D.
Address �� .
Place of Burial (or Removal) -
(If body Is to be temporarly held,fill In space later)
Cemetery --4...,.„....:........ r::., Date of Burial —Y ' ' 19
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated partful;4.rs, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis th f I HEREBY GRANT A PERMIT
to i . ./l ; (Address) lf
�the.... 7
to hold tempor rily and the body.
(Uri�t,ertaker or Dery ba charge ofcor " ) (Inter, remove, erwlse di ce of(state howl)
Dated „ c t 19.%.1..k (Signed)( Local Re gist-„,
rar
This it :s sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eetbject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSE ENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o /'
�A��-+,.. was.,Lin L 2 19
te men t o
iLIL-►—
(Name of Cemetery, Crematorium, etc.)
Section 7f1.1i .271 3( Lot No. / 4 f Grave No.
(Signed) (ft Ge3
(person la charge
Address r/7-'1 >
�1-4
Person in charge must return this Permit to V
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re-
quired, under penalty, to report violations thereof.