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Pruyn, Elizabeth 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, Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CoI2CATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town, Villa a 'ste d N t Dist. No.S‘� ji,,,a,CA, unty. ��1 / or City.... Y...... ,� (If ct , give streetddrp $) Name ofd c aseP ,� ' �'(,l t Veteran J�_�� (If veteran, give name of War) Single, married, widowed, �� Sex ............. or divorced (write the word) .. . . � ///k/,p"-'7 Date of Death c' // 19 ..�1/ Age ... e� Years 0- ........... ()Ohs Day Birthplace Cau of Death V .. 1.. .... -t Certificate was signed by M.D. Address Place of Burial or Remo 1 r (If body is to etnporarily h d,.(ill in a ater Cemetery ........,A,. 11.. Date of Burial /©2 ,,� 19;2(' (If body is to e temporarily eld, i in space lat..r The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the same Appearing to be C ETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra- tion, h ve recorded i in my ocal Record wi the above stated Regis ii ed Number, and on the basis ereof I HEREBY GRANT A PER iT ame) (A dares .7 the A,r to hold temporarily an the body (Underta er or pe son aving charge of corpse) (Inter, remove, or otherwise dispose of (state how)) Dated �.�.../D 19 (Signed) Lo Re This Permit is sufficient for the Removal (and Interment or Cremation)of a o at + p tt o likkject to local cemetery or other regulations), unless removal is by common carrier, in which case a Transit P mit(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 S— Z� ��L was ` � 19 (Intermentt or Cetemarieq) (Name of Cemetery,._Cr1T4�. Section Lot No. __ Grave No. 7/ (Signed (Person in Charge) 1 •41 Address i Person in charge must return this Permit to the Registrar of his District within SEVEN (7) DAYS from above date. Ifjia person is in charge, the FUNERAL DIRECTOR or UNDER-i 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 Registrte,. of District in which cemetery is located. ee' 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.