Blumer, Fred NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregiscrar)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. $3 d
• J' Town, Villa W grate d N
Dist. No.v- CC i County /a ... or City
(If city, ive street .cltireorr
Name of deceased �'Z ' �7 .., Veteran f �7 r 6U
• (If veteran, give name of War)
Single, married, widowed,g �/ >
Sex „L or divorced(write the word)C�Ujejtvij,.1
Date of Dea '> 192 '
Age ears.... Months Da Birthplace
Cause of Death .... ..
Certificate was si y M.D.
Address .. . .... .. . .. �-oale �'1` f
Place of Bur' r Remov I)
,. .
(H body is to�e mp�atily ie�ld, (iI sp l erj L
Cemetery ...t Date of Burial 9'— 7 19
(If body is to a 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, D SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in ocal Record wit he above stated Reg' ered Number, a on the basis thereof I HEREBY GRANT A
PERM
... • ' . r�
(Name) ( re V
the .... . . .. to hold temporarily . i . ... .. . the body
(Underta er or person avin ch a of cor se) t ter,re e, or therwt�pose of (state how))
Dated ., — .........19 .... .C.( (Signed) 4417.4 Loc aTRe
This Permit is sufficient for the Removal (and Interment or Cremation)of a bo. Ito any part of the 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 was 7/2- / 197
(Interment or Cremation)
(N�me of Cem ry, G ;
Section _a, Lot No. cA.5 Grave No.
(Signed)
(Person in Charge)
Address
Person in charge must return this Permit to the Reittar
of his District within SEVEN (7) DAYS from above date. I o
person is in charge, the FUNERAL DIRECTOR or UND
TAKER MUST SIGN ABOVE STATEMENT, write acrose
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
7
SEXTONS, FUNERAL DIRECTORS and UNDERTAKER'S,
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.