Bennett, Tanya NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
VilCage, or City) in which the death occurred after the FLING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 1
// //' J I '' Town, Village Registered No. I
Dist. No. ' (..P.u./ County....14.2a,c.C. ...N or City .t ... C ti.,j FCc U-S.
/ (If city, give street address)
!lame of deceased / &.�<.ci f_c.Lli,t.� -. ,U. Veteran
r (If veteran, give name of War)
Single, married, widowed, ` <
Sex „. L`:�:-n,4,../ or divorced (write the word) .....� . t�-�j.1..C__ Date of Dea . f(lll yy--/-.. ./.....19 1
Age 0.. .Ct_./ Years ont s Day / Birthplace... (''=�S .!"Cc. L5
Cause of Death ..,. . ,?_. .' i r. :'.C'••
Certificate was signed by 44 J/.46.Q.. .. .......OT . .��, M.D.
J �-^� -
Address /a? .S..f........... 1. .I., ..e... . .. L../. .� f�/ . ) /�../ .
Place of Burial (or Removal) .... ...1....Li.0 '!- . `.c..t..e.. .tLS......:.<JE'
;If body is to tempos ily t)e,d, fill in space later)
'emetery .ci.u.� t e.J m 0 & Date of Burial �O u, (� 19.7 ..
;If body is to he temporarily held, 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 Number, and on the basis thereof I HEREBY GRANT A
PERMIT-) /� / / �/ / l f
to C e��' /`ti�(J t?i�C,l ` �K' u i C... ( 3 6- 44/ a-e' • IL•...... l..EN..L �6-1 S
Name) ( ddless
the 'rt1 . .P.. 1. to hold temporarily and �� .<, the body
(Un grtaker or p�Krson having charge of corpse) (Inter, ove, or otherwise dispose of (state how))
Date ..l.G!:Zt1.-a.7 ,:/....4,9 19 7 (Signed)
L Re trar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to e S s�e��i to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit( No. ir
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` ' 6.)'i``` `' / was ��A-L / ' 19 %P.-
(Interment or Crernatits-
// 7 /(VC 2 lfc /-..4/
(Name of Cemetery, Cr na#aritrtn =ett_.)
Section - Lot No. Grave No.
(Signed) <`A� ;7 l_ . �y ;c c
/` (Person in Charge)
Address / % C� t� / 7
- ��
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 U D
TAKER MUST SIGN ABOVE STATEMENT, write acro
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Registi^a
of District in which cemetery is located.
. la
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS4�.
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.