Lilly Sr, Lewis NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ear 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.
/ Town, Vill e, Re to No !�
Dist. No .6 6 ( my � or Ci r� � f`' !r
1 (If c' ive street address)
1 .
Name of deceased: ... t, K r Veteran ... . —`�
/ (If veteran, give name of War)
Single, married, widowed, '
or divorced (write the word) . ....... ......A--q Date of Death 7:2" / 193�
Age.. c41,-- Y Months ys /'� Birthplace ? • y
Cause of�eath .. ...' `.. . ::��,:. 1 '''tiZst..S�'
Certificate was signed by ! 4,61... - - }:;h -<. ---v rY� - M.D.
Address S (t �t=4'141......4,, .k:..... .5%u:1-.2
Place of Burial emoval .,... . .• •,• z�".
(If body is to be m rarity he d, fill in space r
Cemetery ........ _ Date of Burial .../ � Y 19 7,/
(If body is to he emporari y 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, have recorded ' ' my Local Reco with the above stated RegiQ red Number, and on the basis thereof I HEREBY GRANT A
PE I ,
CJ
( ari(e) j ( dt)res }
the .. 1.,. to hold temporarily and ,.:. the body
nderta er or person having char a of c pse) Inter,'remove, or otherwise dispose of (state how))
Dated A72- — = ..19 .. .�/...... (Signed)
Lo
li
This Permit is sufficient for the Removal (and Interment or Cremation)of a body any parr of t.._ State s ject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit P it (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 -1-171'614/4was A19
(Interment or (' - v^),
----- -t-e I" -e'1/�'
(Name of Cemetery;Cretnaterrrxt,-ete: =
41/
Section Lot No. c042 `b Grave No.
(Signed - 6-e 2-2-1-7 „,
41.1
(Person in Charge)
jeA-- , ,,,e,.. .„. , --__-,,,y
Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. I ,g
person is in charge, the FUNERAL DIRECTOR or UNDERUNDEIR
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 Registr '
of District in which cemetery is located.
.r,
s
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS,
violating the law relative to the return of permits are liable td'
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.