Vaughn, Frank NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilfage, 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.
, .stere No. —0,
Town, Villa
Dist. No. $6 o I County or •ty .,
..) (If cit ive str.eet a dress)
6.)
Name of deceased 1/24ef24 - Veteran C; '
N (If veteran, give name of War)
Sex '-' 11(.122—"" Single, /#9.
marriedl widowed, —
or divorced (write the word) Date of Death 19
Age ,2,Cause of Ye, ---i._-- •
onths_ /7476:t.rptiZtlace
, f
Death j
Certificate was signed by , , ..., ./ , M.D.
Address /...,,,. ' ) 1 - erg,..arn.4v (9=4
Place of Buri -(or Remr ) .44W.A f .... ..... %-?' ,...7
(If body is to b t mporari el; i ps.a e at r
Cemetery .- / "' 4,--,.,-) ,. Date of Burial 9—/7 19
(If body is to be temporari y held, ill in space later)
The C TIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same .earing to be COMPLETE, CORRECT, ND SATI FACTORY AS REQ RED BY LAW, I have accepted the same for registra-
tion, . e orded it in my Local Record wi the abo stated Registered er, and on t e basis thereof I HEREBY GRANT A
PERM re
—Vie-- .,
Name) / \- - --- airaregsr.
the to hold temporarily and the body
(Undertaker or pers a "rharge of c9i1prie) nter, remove, otherwise dispose of (state how))
Z./.Dated — 19 .......... (Signed)
rif72,t.citgariaairt.
This Permit is sufficient for the Removal (and Interment or Cremation)of a body n of t (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit P it (VS o. ' d.
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 { 63-7-7.11-'1"'" was - . , 19
(Interment or Cremati n)
vi->/: • /1„,/
(Name of Ceme ery, Crematorium, etc.)
Sactiert-Lek f? Lot No. P Grave No.
(Signed)
( erson Charge)
Address 3. I id% d ��U� �Z /Ll Y
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. I. q
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," a
FILE PERMIT WITHIN THREE (3) DAYS with the Registra ..
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.