Ulatonesku, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 C RTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /,-)
Town, Villag R 'stere No. �(
Dist. No. J�C} l Count 6 � or City.
(If city i 'e street address)
Name of eased Veteran f� �
r (Ifsveteran, give name of War)
Single, married, widowed,
Sex , „. , or divorced (write the word) ........a/V4 -ed Date of Death /12-. 19 ..7�IL..
Age... Yea — onths Days Birthplace.
Cause of Death .. ... .
Certificate was signed by - M.D.
Address 1J 7»
Place of BuriaRemoval .., CP
(If body is to bip
orartty h dl, Fi(T in a e er) /
Cemetery Elr. - ... Date of Burial (02 �/U 19 7(If body is to hporarily 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 QUIRED BY LAW, I have accepted the same for registra-
tion, h recorded it in m Local Record wi the above stated Regist r d Number, an n the basis thereof I HEREBY GRANT A
PERK
to ...... -- � 7
Name) i (/mares?
the 1 e to hold temporarily and . .,,. the body
Dated 19(Undertaker or Belson haviyg charge of core e) (Inter, remove, otherwise dispose of (state how))
/. C�Jj I (Signed)
tr
This Permit is sufficient for the Removal (and Interment or Cremation)of a dy to aTiqr c
p t.. e t e (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is r uired.
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 o Cc% kwas sZae7. 19 7/
(Interment or rreanr+ i-
n i
C—, :)."---11--e. V/C-e-4t
(Name of Cemetery, C
Section Lot No. 69 Grave No.
3)
(Signed 4411
(Person in Charge)
Address �% ---&31--a 0z ,
Person in charge must return this Permit to the Registrei
of his District within SEVEN (1) DAYS from above date. If no,,,.
person is in charge, the FUNERAL DIRECTOR or UNDER1
TAKER MUST SIGN ABOVE STATEMENT, write across the°
face of the Permit the words "No person in charge," an ..
k",
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.