Du Four, Thelma NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rai" 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
STown, 5Dist. No. ty //L} / - or City
(If city i e s reet adGress)
.
Name of eceased (YeLdt/T164...,/ S.,,..4.4._ Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) ..... .... ....Date of Death/ S—6 19 ...2.
Age �� ears Mo D�''s pp Bi aoe....r - `�
Cause of Death • v ti1'�t.e� "
Certificate was signe by,... /i.. M.D.
Address t �... .. ......... �� 'fin
Place of Buri l (or Remo al .... .4, .. ......I..��.
(If body is to b t mporari h d, tl� n space l r)�
Cemetery .:._.. ... �..--'E.-,--,... Date of Burial 19,�11
(If body t, o be tempor rely he , fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same pearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, e r ovrded it in my Local Record •ith the above stated Reg• tered Number, and on the basis thereof I HEREBY GRANT A
PER g
(Name) �<t27).(A82s5
the .. . .. .. to hold temporarily and the body
(Underta eror per on h ing charge of copse) (In remove, or otherwise dispose of (state how))
Dated 19 ....:/..7 (Signed) ecf
4.a
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y part of t._e. 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 ',.E/VI was )71a-A-it 19 7�
(Interment or Cremation)
arrut7
(Name of Cem tery, Ctcmatoriam, etc.)
Section 1 `tip'* Lot No. Grave No. g'
(Signed)
Person in Charge)
Address J 5
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 werds "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.