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Barber, Alpha Pl - NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT «' This Permit can be signed only by the Local Registrar (Deputy cc 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. Y Town, Village Registered No. 7 Dist. No. S(-i ') County 4v - or City Q (If city, sic street address) Name of deceased ®`1Z" 7f . " Veteran ....1 .. t"' tw.,-,a, (If veteran, give name of War) Single, married, widowed, Sex or divorced (write the word) :N.", Date of Death T - ( e 19 / Y... Age J-4.- Years '� Months C� % Days Birthplace rvi • Cause of Death /�, �v Certificate was signed by ^�'�-�TM-- J '7 M.D. Address ,,,j.,tz,,ti,.. ?r F � 1,.. Place of Burial (or Removal -..- . •.. (If body is to be temporarily he d, lill in space later5 Cemetery cam=-_— Date of Burial ? -(1--- 19 .1 y (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- tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A PERMIT e7 to /k(`/�"-e'-- `'' 1( Y..... ` o.�+�.f'q -a. °.t-i?o�-ar 4�t� (Na e) U (Address) ©j� the to hold temporarily and '„.- the body (Undertaker or p rson having charge of corpse (Inter, remove, or otherwise dispose of (state how)) Dated ..t t 1 19 `1 `-�... (Signed) 0'..--)--t. °. Qom- _ Local Registrar This Permit is sufficient for the Removal (and Interment or Cremation)of a body to 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) rENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date ot=�� < d`Gt-r`C/ was - t)i - 19 /2/ (Interment or (Name of CemeteryX— Section Lot No. / ,/,''' Grave No. "- ' /�1( ` ' ' /4f 4-I-1_ (Signed( ) (Person in Charge) Address jA_ -(714e /(" Person in charge 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.