Root, Augustus 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 C,ERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
l Town, Vill r 'stered No ,
Dist. No.SG°1 County..L4W 4 r City... x
.....
✓ (If c , give reef a dr
Name of deceased . ....,/, , Veteran
(If veteran, give name of War)
l,, Single, arried, widowed, �,/f
Sex .„ „ // �5�.-� or di •reed write the word) ... .Y,l.Gdrtit,tid Date of Dewy C 19
Age `.. A:rs.. ` Mo�/s ... Days Birthplace..
Cause of Death ! - /
Certificate was signed by ... . ....... ;;Jr 11' M.D.
Address... ^.:..'..: —
Place of Bur l (or Re al .... / ., .. . ..
(If body is to mpor il d, 7' space a er` ��/
Cemetery ... �.. ..... ...... /: ... Date of Burial ?—'( 19... 7
(If body o e temporarily h; d, fi 1 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, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, h e recorded it in my Local.Reco with the above stated Re •sdered Number nd on the basis thereof I HEREBY GRANT A
PERM
to (N me) Y� ! (A ?ess2`
the to hold temporarily and the body
(Underta cer or 7is n t)�ving charge of.gor se) (I , remov>�Ur otlf wr dispose of (state how))
Dated fT / 19/................ (Signed) ill•
O/(o
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)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of itdl was 444- //,, 197 t(Interment or Crem )
41ut
(Name of Cem ery, Crematorium, etc.)
Section 1 S,�'.. Lot No. / folv L Grave No. 2
(Signed)
(Person in Charge)
Address .g ,6. A'I Y`
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.