Jenks, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar" 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. yCY°
Dist. No. 01\ County.\,....?�C~>- or City ^�� c\_00.0
(If city, give street address)
Name of deceased ...... .... p Veteran c\:C.D
(If veteran, give name of War)
Single, married, widowed,
Sex C.QQ or divorced (write the word) . Q»1Xa: ......Date of Death ... • CI- 19 1'3
Age Qj\ Years Months Day Birthplace 1 ,1D..1_,.. 0.. .c,
Cause of Death CX,S\-\0.3Nri•• -.e. rD
Certificate was signed by .. r,.__Q9Z)-1\-St(P, M.D.
Address 3. . Z-7
Place of Burial (or Removal) ��'�-r-A ,Q. ,9 .
1 fill to s ace late
(If body is to be temporarily he d, p 5
Cemetery � ...` . Date of Burial , N.3 191.3,...
(If body is to be temporarily held, ill�n 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-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT •
to
_ (Name) ( ress)
the to hold temporarily the body
(Undertaker or person having charge of corpse) er, remoi or oXiroldkEse of (state how))
Dated 0 Z ( Q 19 7`-' (Signed)
local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body 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 F 19 /
(Interment or Cre ation)
/ . '// r j? � )
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
\ s(‘
(Signed)
(Person in Charge)
Address � -H?1 �.
9
Person in charge must return this Permit to the R i rar
of his District within SEVEN (7) DAYS from above dat no
person is in charge, the FUNERAL DIRECTOR or UN
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge,Lond
FILE PERMIT WITHIN THREE (3) DAYS with the Regr
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAS
violating the law relative to the return of permits are liab?'e 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.