Ingalls, Florence NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fgr 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, Village Registered No.
Dist. No. 35.69 County..ORANGE or City 1 OWN—Of WOODBURY
(If city, give street address)
Name of deceased FLOR.EN.CE....I.N•GALLS Veteran NG
(If veteran, give name of War)
Single, married, widowed,
Sex FEMALE or divorced (write the word) Si NEL.E Date of Death 1.242 1974
Age 5.7 Years .Months Days Birthplace .MA.I.NE
Cause of Death RE.NAL....FAI.LURE
Certificate was signed bv ...T.HEO.D.ORE....W......NEUMANN.. MD M.D.
Address FAL•K.IRK, HO.SP.I.TAL...CENTRAL...V.LLE.Y...4 NY
Place of Burial (or Removal) ...T,QW.N...AF... Q.0 EKSB.URY N�
(If body is o be temporary held, fall in space later)
Cemetery EEL,,.EY L.EMET.ERY Date of Burial — -74 19
(If body is to a temporarily e d, i 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, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT (�
to KE.GAN....&...BENNY. I.N.C., QUAKER...ROAD., G7l N[�S f.ALLS.,�....NY
(Name) (Address
the UNDERTAKE.. to hold temporarily d I. TER the body
(Underr{{ er..pplI��person aving charge of corpp,se) (I ern ve, or o fires s disp of(stale how)
Dated 1 -1L— 19 .../...4......... (Signed) .... `�(J //�Loce;,.. egigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t,.e 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 INTERMENTS OR
CREMATIONS ARE MADE
Date of -' F%VYVtl4M/ was 19 71
(Interment or Cremation)
(Name of CAI ery,
Section . Lot No. --Grave No. ^—`-"
(Signed) f!f��y(/
(Person in Charge)
Address /e j /& ,et
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 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.