Smith, James 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. `
Town, Village Re ere Noaes
Dist. No. �; /..... ... County or City '1.0 i
c qIf ' give s reer
Name of deceased ... VeterZt,/,/
(If veteran, give name of War)
Single, married, widowed, '
Sex or divorced (write the word) ...... ...... Date of Death�.'}.fd 19 �
Age ars n s Days Birthplace /!.. y
Cause of Deat �+- . .. ,C
Certificate was gned by . e. • M.D.
Address .. V//�!
Place of Burial (o e oval)
ff
(If body is to be to par rly held, ill i s ce a r
Cemetery ,�,2 / -1..,, Date of Burial /� �7 19,�s-
(If body is - be tern orari y d, fi in space later)
The CE' CATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same gyp. - g to be COMPLETE, CORRECT, AND SATISFACTORY AS UIRED BY LAW, I have accepted the same for registra-
tion, ha corded it in my Local Record wit the above stated Regist re Number and the basis thereof I HEREBY GRANT A
ame) aeSs
the
.. . ' . . . .. !..., to hold temporarily and the body
( der a er or person Navin arge of corpse (Inter, r ove, or otherwise dispose of (state how))
Dated 1,., i i 19 ). (Signed) .,.,
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any art of the taS to (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit( S 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 Grernotaiew�--__
(Name of Cem�cery, C - *,_._s__l
Section Lot No. ""� Grave No.
(Signed) L44, Wks /
(Person in Charge)
/81
Address
f/
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.