Chadwick, Keith NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ram` This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Vilrage, 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 Villa Registered No. 7'
Dist. No. ! / County C aG or City L- �1-•-•-
7f •�'� give street address)
Name of deceased ✓ �- ,t;e4 4 � �x city, g
��f/// Veteran "he"'
(If veteran, give name of War)
Single, married, widowed, �_ ,!lp'
Sex �� or divorced (write the word) Date of Death 9" 19 73
Age Years Months .... / D9 o> 1`) Birthplace i,
Cause of Death , c'- - j �ti� j
Certificate was signed by /� fE M.D.
Address .•pryr�, , ,
Place of Burial (or Removal) n- / 14 ,
(If bodyis to be mporarily he d till ` ace'later)?
Cemetry p �K p�- L Date of rial '2-6 19 7,3
(If body is to b empora • 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•
tion, hay recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PtERM �P - el. I ' ye,.,74 j 72
(N016
the e/J ,/ to hold temporarily and �Xi� the body
Date n erta r or p rsAi having charge ofcorpse) 67nter�✓rerrve�, o therwts7s Wf tot w))
fv .Z.ti (Signed) /c R "
Local Registrar A4,,j`,
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to to cemetery or
other regulations), unless removal is by common corner, 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
..., - - -3
Date of'--""'2�� ��'�•1��-w�-��' was ,� 19
(Interment or Cre, t Ean)-
/
(Name of Ce etery, Crrinatoriumic.)_. ,
Section Lot No. Grave No.
n /
\G r'
(Signed) `,,
(Person in Charge)
' /ri/
erson in charge must return this Permit to the Registrar
of his District within SEVEN (1) 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.