Schmidt, William •
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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 CERTIF WATE OF
DEATH, LEGIBLY WRITTEN IN DU ABLE BLACK INK. SS Town, Villa ',is-Wed,'
Dist. No.'$6 C County C or City.. .. VJ....... �/
(If cit give scree address)
... ... ..,(.Name of deceased .... ,e, i 7y1 � .. .... Veteran .
(If veteran, give name of War)
Single, married, widowed, r`
Sex or divorced (write the word) :22g:atiC Date of Death —‘ 19 ...T...
Age S ars.... a✓ Months s Birthplace.,..
Cause of Death/ ��AO
l.. . r Q�
Certificate wa4 signed by....�. , M.D.
Address t.� �Ij )?
Place of Buria r Removal i /„Aq/1-
(If body is to to oranly h d, Ii s a e later
Cemetery /..L1 ... . . , Date of Burial %L) •-r .;' 19 7 _
(If body is to he temporarily a d, fill in space later)
The CERTIFICATE OF DEATH cons ing the above stated particulars, having been presented to me, after careful examination, the
same aring to be COMPLETE, C RECT, AND SATISFACTORY A EQUIRED BY LAW, I have accepted the same for registra-
tion, av recorded it in my Local cord wit the above stated Regi ced Number, a on the basis thereof I HEREBY GRANT A
PER IIT
to .... .. ')?t t S J
f(Nam � � /4d�'res
t e OLP' '�_, to hold temporarily an the body
Dated ndertaker or pe,rs)on haul g)chargeloof c p e) (In remove, otherwise dispose of (state how))
(Signed) .. ,��y
eat tra..
ws
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to 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 IN'}j'ERMENTS OR
CREMATIONS ARE MDE
./
Date of was 19
(Interment or,Crrt+a inn).
r .
(Name of Cemetery, C ``
Section Lot No. Grave No.
-1 " .
(Signed) (Person in Charge)J`
_. . �/7(2 / i .
Address '�a '' ,� r '
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above dat o
person is in charge, the FUNERAL DIRECTOR or Uilipp
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge," a
FILE PERMIT WITHIN THREE (3) DAYS with the Regis?"
of District in which cemetery is located.
4,00
SEXTONS, FUNERAL DIRECTORS and UNDERTAKER;
violating the law relative to the return of permits are liable tp
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.