Butz, Karl Form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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 Registered No._ro
Ville
Dist Noba -7...County...W.001W4 or City q ...,....t..g.,e,c._:(r .:_a....ff,.44.
(If city, give street add s)
Name of deceased. /(12.4.-ee- ,4° -c "-,.. Veteran
Single, married, widow: , (If veteran. give-name of War)
fel - A
— /6 -
Sexlle...a....c.,...4., ,,,...or divorced (write the word)..714.t.g.1.4e,W Date of Death....,././,......2.. 19.a
Age Z Years Months Days - Airthplace./4"0# — , ". . . ....... . ...
Cause of Death.e.et.:7*-arrn..-,.../.. az.-&-7 ...4ek-A-:5.MA-g;r:-7 ,../.- 04 .---f .. . . . .. . . .. .,. .c.--,. .....
Certificate was signed .._ . .?.t.: . ..., -A-07 M.D.
..i •- ;774 I
,/ t ---c-- —.ek.k.<1.: k -7
Place of Burial or Removal)
(If body is to be porarily hel ,fl space la r)
621
Cemetery... .-3<2.4...... . 4., . .f,e.e -7
"tem.(
Date of Burial i i ---- / 7 10e
(If body is to be temporarily h€ld,flu in space later)
Thq Certificate of Death co taming the above st4ed 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
Nu and on thobar h .„.V HE BY GRANT A PERMIT _
to ./4.k.n4;ai 6 Z
iro
./.'0471,&srol-OZ. ..9‘.
ANa ress)
the....--el.0.04d4.2.:Z.a.-- e...e..1 to hold temporarily an ,......- 0.-7,-,.-- -al the body.
(ITI3O1166%pr person having aarge of5fpae) ter,remove,or otherwisbose of(state howl)
Dated4----4'-2 7.- V e. I ? 19,3 (Signed) (1.-=--.c. --7---2 4..---erra-
e.A.- Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo4to 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.
e*,.2 C- _e to
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CATIONS
ARE MADE
Date of/_' /= �` 9,'' tweeas
(Interment or
/3
( sae o Cemetery, Crematorlum, •tc.)
Section Lot No./71- Grave No.
(Signed 747) �:� G'`",M - , 1.. E
� (Person in charge)
Address l.C�
Person in charge Heist return this Peiinit 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.