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Loveland, Lawrence NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT «' 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. n6 ff�� Town, Village Registered No. J Dist. No,��' ( County vl/..L�!t -- or City L.V.e.‘).V.d (If city, givq s)regt address) Name of deceased .&. . Veteran u (If veteran, give name of War). Single, married, widowed, ��j/- / Sex ....R or divorced (write the word) .. !( V:h l Date of Death-.....l07rZ 19 7 Age Yea a+ .Month} Days , irthplace l�e�/Y� Cause of Death � tz�s./slip��..Q.. X'�t.v.C1 !'4� 401-©IAA k ,,,.C�Cf2 c./ 1.(4. j`(e�j ll` Certificate was signed by ...."fi ..Sl.!'.4,.. V-- f .V.ZAj.i' ,,, t M.D. Address �z, .V.:Vt!�F.:4.�c V a�PS to V jz io z Place of Burial (or Removal) /Q�c:'A .....,a.,( , .U,.q. <c (If body is to--temporarily he`d fill in space later Cemetery `[f(de...f�I.en-4.r.'......r.e-(,2y] Date of Burial (0/.(.. 19 7 4-1 (If body is to he temporarily 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 REQUIRED BY LAW, I have accepted the same for registra- tion, jyax.e,recorded it in my Local Record with the above stated Registered lNuJmber, and on the basis thereof I HE �YY GRANT A J (Name) (Aa�ress5 the ....Pe•1'. (� to hold temporarily and .... • - _ `- P Y .•.•. fir the body (Underta eror person hav ng_charge of corpse (Inter, remo.• ; othe • .i e of tote how)) Dated .........t L7 - .7 19 ..7 (Signed) 'f< This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part f e State (subject to local cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS o. 62) is required. l'OItM VS. 61. (REV. 6/63) (A2-248) _-- ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE t.... !r//�7 Date oas 19 (Interment or Cremation) (3.1- %(..--166(4..)%- (Name�of�Cemme ._/tery, Cvmatorium etc.) -- /1/1 me Section c2. Lot No. //U—d Grave No. / (Signed) ,______---' (Person in Charge) Address 1-�/3 " t S4,0' el. 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, d FILE PERMIT WITHIN THREE (3) DAYS with the Re r of District in which cemetery is located. SEXTONS, FUNERAL DIRECTORS and UNDERTA violating the law relative to the return of permits are liab a penalty of NOT LESS THAN FIVE DOLLARS NOR MO THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. law will be enforced. Local Registrars are required, un penalty, to report violations thereof.