Hovey, Mazeda NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
j' This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
VilCage, 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, Village ,Registered. 'J".
Dist. No. 6�I County2/4/a-'1/122-1-1-- or City k'r�"�
4'�✓� (If city, ive street address)
Name of d eased ....... . ..... ..G'. it ,,, .. 1 C`z%--\_ Veteran ' ...i
Single,
a (If veteran, give name of War)
? or divor divorced the word)(_,e_.() 'mac Gig Date of Death �* 19/"
Sex . .. ... •. (write ..
Age..... C Years Months ys /' Birthpla i . tCause of Death
Certificate was signed by
M.D.
Address t -
Place of Burial r moval ... k'�..'t.....„'C •/,
(If body is to be emp arily h i th spac 3ter)
Cemetery ( i , ,.�,y_ .. ..e..z,..,.......... .�K ... J Date of Burial ..... e".S 19 2 cg
(If body is to he,remporaril'y held, fill in space ater)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same . .. ing to be CO ETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ave r co ded it ' my Local Record with the above stated Registered Number, and on the basis there f I HEREBY GRANT A
PER IIT
tO
i ane) `� to -ss
the ,.Z 4, AWE 2 to hold temporarily an ::7..„ the body
(Undertaker or erson having charge of c.kpse) ( , remove or of twist)e dispose of (state how))
Dated -- .�.$ 19 y (Signed) ocr� ag
tgtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to ny 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
_ 1 c .,/
Date of �} ` was _-'' 19
(Interment or Cr rn iLu)-
(Name of Cemetery, Crematorium,_etc.)
i (, !i 1-% / , /;
Section -' I Lot No. ' J Grave No.
'
`
(Signed) t '� )i i
(Person in Charge)
Address / / ;J/ / / ' `' / / /-(
Person in c harge 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 Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of 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.