Heisler, Norman NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rgr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
--CbL2
Registere;1...flo.
c.`--Z-c, Town, V.i..1...13n /-
Dist. No. - County - --.e.1- 1/11--/ or City i(e'
of city, give street iskiress)
Name of deceased 7if - .''-0,4-, e ' ./--;---,,,a-,/
Veteran /-...Qze......"_e
(If veteran, give name of War)
----I.-1
Sex 7
/ l Single, married, widowed, ,
or divorced (write the wo 4-- 1±rd) ' -4-4') 4/ Date of Death .,.. 4 19 3V
Age Years i .Months , Days ,,- 1 Birthplace C.,/ Art-cf.--
Cause of Death ---i----71 'c•_-_- - /7 '; le
,--
Certificate was signed by /. /---1-9---e IeV1/.*1 M.D.
Address ...,...e.:1-...- #4.- -:),.7
...# -
Place of Burial (qr Removal ....s. .-:‹47-247?...4 k c--;
(If body is to be teMporarily he d tar tn`-§p e4 er
b
Cemetery Date of Burial 9 - ' 19
(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-
ereof I ii-E)REBY GRANT A
tion, have recorded (4.--in--my\Local Record with the above stated Regis ered Number, and on the b s• ath
PE
to
/ • i' -frZi Name)
i (Acraress)''''-•'' L-yr
the ' ' -'.--'-- ' '-"---: --0 ' to hold temporarily and ,_ - /'' --- the body
(Undertaker or,erson jzaving charge of corp,ste) •nter, remove, or hiecr;tif dispose of (state how))
(.....
Dated — ljt 19 '// (Signed)
• Xi L s'eits,..
This Permit is sufficient for the Removal (and Interment or Cremation)of a bod any part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transir' ermit (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 " 12= 'Zs-s 19
(Interment or }_..
(Name of Cemetery, L iVaerrie __
611
Section Lot No. Grave No.
(Signed "
(Person in Charge)
Address ' eel
..
Person in charge must return this Permit to the Red‘ r
of his District within SEVEN (7) DAYS from above date. If
person is in charge, the FUNERAL DIRECTOR or UNDE
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words "No poson in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE
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.