Mc Griffin, Elizabeth -111 1114.,,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregiscrar)of the Primary Registration District (Town,
Vill'age, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER IFICATE OF
DEATH, LEGIBLY WRITTEN IN DU ABLE BLACK INK.
Dist. No•f 0/4 ,Co ty t 110
Tovm, Villar / ,
4
2 .. z
,
Name of d ase 337C. 1 0' (If • ive street address) --"/.
Veteran d
(If veteran, give name of War)
Single, married, widowed,
Sex . or divorced(write the word) Date of Deathrf 197.fr
Age s M ths Days Birthplace
Ca se of Death .
Certificate was signed by ` M.D.
Address - .
Place of Bu 1 (or Rem• •a ' -n v .,
(If body is t temporarAP cl-T ". space ater ,,
Cemet . .... ......._...... .. . .. . _ Date of Burial /Z—/ ' 19....2$
(If body is to he tempo ily h d, fill inS.paCe.later)
The CE• FICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same a,p. - ing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ha recorded it in my Local Record wiA,Yth t.le ove stated Regi red Number, and on the basis hereof I HEREBY GRANT A
P *MIT .
...littAioca d--
(Name) (*dare s) 'i7‘
.. ,
the . i iff to hold temporarily and the body
itinCie'itakei.gi: person Noting charge of cor.,Es (In remove, or otherwise dispose of (state how))
Dated // fit' 19 /.fr... (Signed) .
"lejli4CE&g
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y part t
..,e • ct to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is requi
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
di OF PREMISES ON WHICH INTERMENTS OR
t CREMATIONS ARE MADE
t
Date of was 12,c r 4 /? 19 7 T
(Interment or Cremation)
(Name of Cerdetery, Crematorium, etc.)
Section -Cr Lot No. c;77 Grave No. I
(Signed) (L''/; ._4-,t..L%
( erson in Charge)
Address 3 Yt c 61 ) 464uL c L,/C Y
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. If o
person is in charge, the FUNERAL DIRECTOR or U
TAKER MUST SIGN ABOVE STATEMENT, write across t
face of the Permit the words "No person in charge," an
FILE PERMIT WITHIN THREE (3) DAYS with the Regist
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS:^
violating the law relative to the retumof 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.