Shaver, Henry NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Mr This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DUR BLE BLACK INK. /
Vill Regis ere o. �n.rT,s
� ' r r i Town, /��J,,
Dist. N �d County.. .. "✓(A'l.t,l or City yX.k:r."... .�. .C.4-.:.... ., �/ '.
(If city ' ,eistreet.a Tess)
Name of deceased Ai.Q ).( /1. . Y y`'-11/ Veteran ' !/C.) •
C (If veteran, give name of War)
Sin , married, widowed,
Sex „ l or 'vorced (write the word . ... . 4.:C.C. Date of Death ..././ /? 19 ..
Age GP Years ...., Months D.y Birthplace
Cause of Deat ..... .. ... ...... C2.. . .r��-�G::4 4../
Certificate was signed by 151..&(-/rgd .
.. M.D.
Address . `
Place of Bur'al (or Re oval -(2%.r1, `G�
(If body is to vie mpora ly d, (il�'in a ' later �/ /`
Cemetery ..L rr.(,.... s -" Da{e of Burial ...✓�; 2 f 19,
(If body is to he tem rart y held,-fill in spat dater
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same aring to b OMPLETE, CORR T, AND SATISFACTORY A REQUIRED BY LAW, I have accepted the same for registra-
tion, ave re orded it my Local Reco d with.the above stated Reg's ered Number, on the basis thereof I HEREBY GRANT A
PE T '/
i
to -f {Name) r.. ...ova. esss
the ....... 4-.' to hold temporarily and .... the body
( ert ke `or/pers having charge of corpse) (In , remove, or otherwise dispose of (state how))
Dated // - 62. ) 19 7 J . (Signed)
.CZ
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y part of tic State su t to local cemetery of
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
.. . le ` //°v:/ 19 ,77 Date of was
(Interment or C-rer ,a;an.)-_.
(Name of Cemetery, CraitiPeerra -
--
Section Lot No. Grave No.
(Signed
(Person in Charge)
Address
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 Registt
of District in which cemetery is locatad.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKER.
violating the law relative to the returnf permits are liable t
a penalty of NOT LESS THAN FIVE DOLLARS NOR MOR
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.