Stewart, Mae NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Lir This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Viltage, 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. cJ�yl
/� � Town, Village Registered No.
Dist. No. 'sue 0 I County L.�.1rn or City a.
(If city, give street address)
Name of deceased '�--sc,- V teran
(If veteran, give name of War)
Single, married, widowed, ., &%
Sex le-,-,.--e-e_e_____ or divorced (write the word) ..Date of Deat}t_ 19 .7>
i.
Age 73 Years 4 " 2� f pcMonths .f Days Birthplace / ... .
Cause of Death .• . — 0 "''� e (�
Certificate was signed by... .. �4x<iC.�T M.D.c.�r�... . .... ....
Address -
Place of Burial (or Remo I) .... / )7 ' 4f,444e,-,,,---g--ti.A-7
(If bodyis to be tem oraril eld, (+"�1'ins ce terj
Cemetry p -� .:..L. ti 4,1 v rn. ty Date of Burial 19 7-5--
(If body is to he temporari y held, fill in space later)
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, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT �i �Ca 1
t,� Gc�c rs-F.
JJ,, (Name) (A �ressj
the t e:� a a k� .- to hold temporarily the body
(Undertaker or pern having charge of cAr e) (Inter, move r otherwise dispose of (state how))
Dated ./ 19 (Signed) ) In / 04...._
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 //19
(Interment or Crimea-tier,)- e
---(97-•""t"1.1„,
(Nam met r , C
Section Lot No. ACC---Grave No. 7
Si
gne )d * ,1„ 6/2
(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 Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the retumof 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.