Duers, Isabel Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can be signed oaly by the Local Registrar (Deputy or subresistrar) 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— Registered No.__._ .` ._ /
Dist. No el.-County , or City
(If c.r`t.----(Z.,
e street address)
Name of deceased --e- ,er �. '-c--e::!S:Q� Veteran
Single, married, widowed, (If veteran, give name of War)
Sex31)
Color or divorced (write the word).�1 Y`'7`� Date of oath... ��19`% `'7
Age �, Years Months . ..D irthpla
Cause of Death C .... ... Days,... —a .... .. . ... - z
Certificate was signed by Q M.D.
.............
Address l.f.....::. .....
Place of Burial (or Removal) --' --1 - 4
(If body is to be temporarily held,All in space later)i
(If
metey iry..a mpo-(-- ,y held, in space later)..�^��`--)Y`y -"—z Date of Burial - i� 19...d.
The;Certificate of Death containing the above stated particulars, 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 d on the ba,is tf I HEREBY GRANT A PERMIT „rjo
r--, - - -
the . .j(� '�:J to hold tempo rily nd �_ the body.
( ndertake or person haying charge of corpse) (Inter, mo o e dispose of[state howl)
Dated.. ... /7' 19..DT (Signed) ' F
Local Registrar
Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (oubject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
L (Lei c -te
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of:7%. ^(,s`%,,.,.`.f —was cL r l9 C5 0"
(Interment or Cre tion)' i
1.....", 4.:-.--7/7
(, .4/2.:'----. ,' ......‹. '"'.- (-71- 1"..."--42(..."(.i-
` (Name of Cemetery, Crematorium, etc.y'
/Section Lot No. Grave No.
(, 4
(Person in charge
`ram / 1 , �.
Address o
d 4.-
'9 , 9 . . 'SL �-'�-
_*(r-----...-j 7* de.--e_16- ' ''' ' '
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 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.