Hogan, Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ggr 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, Villa) (�',
R to
Dist. No� ( Co my l ' �'✓�/�{. or City ��� ✓Li �ci y
(If ci y give st eet ad ress)
& -2--)� —n, fj
Name of deceased .... ' � C��,%x-,_- Veteran ...,ll`:� ' /� "/9-5° � ,�:(_S�
(U/ (If veteran, give name of War)
Single, married, widowed,
Sex ... ... ..1'(.. -- or divorced (write the word) .. .... :I<?1 Date of Dea 3 ` 19
Age �`.4_ j_ _Months .... .. ��irthplace
Cause of Death ... N �
Certificate was signed by ... ,,i-J te %.• :.... .... .... . M.D.
. . C
Address .,L t
Place of Burial (or oval .. . . yv Cam'
j.... . .. / _, -
(If body is to be to r ily he , i in spa later)
Cemetery .- .44:1,, .. .`...'✓.',J Ific4.7. Date of Burial ,. -- /l 19 2
(If body is to be 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, hay recorded it in m Local Record with the above stated Regi ered Number, and on the basis thereof I HEREBY GRANT A
PE . . . . ..,---C.. 0"lk.-Y../1/Ce //-
i (Name) r (A ress)
the '.(, ,y to hold temporarily andi. .i/L the body
(Undertaker or p.e.5son having charge of co se) ter, re orM�r a spore of (state how))
Dated _ /( 19 ... f (Signed) �I��r
Locr,Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body any part of t,.: 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 of - lit k ,cwas :j/// 197
(Interment or Cten)
(Name of Cemetery, Crenpirair etc.).
Section '�_ Lot No. / . Grave No.
(Signed)
(Person in Charge)
•
Address /f / ' /_� ( '/
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. o
person is in charge, the FUNERAL DIRECTOR or UNDE -
TAKER MUST SIGN ABOVE STATEMENT, write across tgtP.
face of the Permit the words "No person in charge,"itd
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.