Clark, Paul 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 CC_JtTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. s U
)) Town, Village
N
Dist. No. (� ount . �l'�` 'vt%% or City /� f�
(If cit 've stree4 addre2)
/
Name of deceased J .._ Veteran.:..........
(If veteran, give name of War)
``//,-- Single, married, widowed, pate of De �`S ,� 19,2
Sex " l,�� or divorced (write the word) .. �/Age.......... .�..� Y ,,Months . a)rs � Birthplace... -) � 7
Cause of Deat G✓.Y'' - '('" lam✓ - x. ....yk
Certificate was signed by '. - .. ✓-F=' / M.D.
Sn .... L Yr. Z
Add ss .' f `',/,
Place of B tal or Rem al) 1 L�
(If body is be temporarily held, fill �" spa"ce t
Cemetery ..,.:-/f ...� � A. , Date of Burial ,,7— 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, ve recorded it i my Local Re rd with the above stated Regi red umber, and on tIle basis thereof I HEREBY GRANT A
PER 17
l
the 'Z✓. to hold temporarily an '.k.1' :. the body
(Undertaker or pers n having charge of rpse)
rs L (I = , remov rot ispose of (state how))
Dated _ — ./. 19 ./ f (Signed)
/ oce.Regigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of ti.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 jy . , /A/
Date of was 19
(Interment or Cmm:__fin)
_ `-(
(Name of Cemetery, Crete-tr.)
Section Lot No. 77 Grave No.
(Signed)
(Person in Charge)
Address' ' `�J�<
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date4 If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across thex
face of the Permit the words "No person in charge," amid
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.