Norton, Fannie 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. }, '---
t�C�f
� J (C'
Town, Village Regist re ll�
Dist. No. `- 0 County or City
J ' f f (If city, give street a/ddresa
Name of deceased `¢� h �'G eteran
(If veteran give name of War)
Single, married, widowed, -
Sex or divorced (write the word) .
.._ ea Date of Death L 19
Age.... Years ,may Mo the Da Birthplace 5,,
Cause of Death /.�.'.�
Certificate was signed by �^ M.D.
Address �r,�f ! r! i,._.Place of Burial (or Rem val 2�,p
(If body is to temporarily the d iil1 i sp later)
Cemetery ..E�... iS:�....(./.. }' ate of Burial 4A- 19
(IE body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated p rticulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFAC ORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in m Local Record with e above stated Registered Number, and on the basis the eof I HEREBY GRANT A
PERMI42. � y % J a)a 449 4/(N ad ss ji.Pek
the to hod temporarily and the body
(Undertake r person having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated .,�'.� 3 19 �.... .. (Signed)
oc
This Permit is sufficient for the Removal ( d Interment or Cremation)of a body t yi of ect to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Per t (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 'I was c �/ 19
(Interment or Creaation-)
(Name of Cemetery, Creep . •raw,-ercc..�
7'7474 )---7.
7` /1
Section Lot No. /7 Grave No.
(Signed) �> ,, ('
(Person in Charge)
Address
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 Registres;;
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE
violating the law relative to the return of permits are liable tort
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE �i
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.