Miller, Rhoda NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 CERT[FICA]E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. (`JJ��
(� Town, Vill a Regi ere o.
Dist. No.--7�'U ( C nt .. �%0�1'�`�"� or City ' (If� zi� street ad ess)
8
12 G
Name of d c sed . �.� Veteran (If veteran, give name of War)
Single, married, widowed, �
Sex .... or divorced (write the word) ./tait'r.,W Date of Death f/,,.. 1922
Age. „,ccr y'(ars. Months Days i lace 95 a..
Cau of Death . .a .. 42-.<4.,.
Certificate was signed by 1 / ) � M.D
Address ... ...- - -r(c,.� s.�'Li/>/ (J
Place of Buria or empval)¢' `-7
(If body is to b t orari y he , i in spat ter)
Cemeteryfbody � Q. 11. ,Cl ,fin u�., Date of Burial /) -3 19
(If body is to be temporarily'held, ill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same Baring to be COMPLETE, CORRECT AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, h v recorded it\in my Loc Record,w't the above stated Register Number, and on the basis thereof I HEREBY GRANT A
PERMI ,)
to .... ........ A' . d— .'Y..:iQ. f�!L< !. —.... ..z4 4x.... ....
(Name /,( aare s)• �i
the .. ...... to hold temporarily an the body
Dated nderta er or p son ving charge of c. se) o rot saikse of (state how))
19 .. 4 (Signed) • � "�
Locr,Registrar -
4.
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 o ���sv� was vli.fi-e—/2 197�
(Interment or Cremation)
V e A,
(Name of Cemeter ,
Section L o "\ Grave No. lS
(Signed)
(Person in Charge) ,____-%:41/1'
Address i&K
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date,!��'"rrJ�f no
person is in charge, the FUNERAL DIRECTOR or Ui1 R-
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No person in charge," nd
FILE PERMIT WITHIN THREE (3) DAYS with the Rear
of District in which cemetery is located.
1
SEXTONS, FUNERAL DIRECTORS and UNDERTA S
violating the law relative to the return of permits are liabl
a penalty of NOT LESS THAN FIVE DOLLARS NOR MO
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.