O'Malley, George 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. ��
Town, Village jU��s,�ered No.
Dist. No. ,7(�C'( County /( vLe4-L_ or City f
t �'�J (If city, give street dress)
Name of deceased .... ( 0 Veteran .G
(If veteran, give name of War)
Single, married, widowe ,
Sex ../ or divorced (write the word)/./ ('l!l � Date of Death .. U — Z 19 29.
Age Y rs Mons ..... Days Birthplace 7!' j7
Cause of Death °Lc... t,
Certificate was signed b M.D.
Address ca zy
Place of Bur'al (or Re val ...„ !. '%
(If body is to tmpo he , n spacer
Cemetery r. rvkS to Date of Burial ....1 19 �,.
(If bod ass to be he tempbraril held, fill in space later)
Y
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, hav/ecord • it in my Local Record with the above stated Regi red Number, and on the basis thereof I HEREBY GRANT A
P :
/,, ' L
•
to ../. .. ... #11/ —r"
iSli(m 1
1--(Nam
�(Aaaies )
the . i to hold temporarily and .. the body
Und-rtaker o erso •aving charge of ca}rpse) ter, remove, or otherwise dispose of (state how))
Dated 19 /�/J (Signed) ,'A
This Permit is sufficient for the Removal (and Interment or Cremation)of a bod o any part f the State ject 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
erl'In (Ayrzo O, - L `l, /?7
Date of was r`/' 19'7 Li
(Interment or Cremation)
L1
(Name of Ceme ery, Crematorium, etc.)
Aro AIAJliet9 Yw SCc Pow / 4- 7 V-S C-yrt,v #E g_
' "Section Lot No. '--' Grave No.
(Signed)
( erson in Charge)
Address 3 S.
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. Ifito
eA
person is in charge, the FUNERAL DIRECTOR or UNDER
TAKER MUST SIGN ABOVE STATEMENT, write across thh
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. ,,
ty
x
SEXTONS, FUNERAL DIRECTORS and UNDERTAKER
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.