Shaw, Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 AC /s .
Town, Village Re tere No.
Dist. No. 6/ County or Cityith tore .•.
(If city, give street addr s)
Name of deceased• a"*. — Veteran... ' '
(If vet ran, give name of War)
Single, married, widowed,
Sex 7:L41'62-- or divorced (write the word) . ..... ...'.Date of Dea , 19 .r�.
Age ` ' Years onths Days Birthplace..
. ..
........ ..Cause of each w ,.�..r-
Certificate was signed by . .. / C�O
���� yA,. i M.D.
Address -� 41 c�,.rc.� � .e 211
Place of Burial orpRemoval
(If body is to b e poranly he d, Fill - pace a /
Cemetery • Date of Burial , /e 19 .
(If body is to h temporan y held, fill in ace 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, hav recorded it in rt)y Local ecord with the abo stated Registered Number, and ory¢he has' thereof I HEREBY GRANT A
PERMIT >> 1�'(/jf
to C3l... \�i��
a Charge
� ZA ,dress)the Q^� to hold temporarily and - e body
( nderta or person having of car so.) ( , remove, or otherwise dispose-of,(state how))
Dated r,t... 19 .7.1 (Signed) �... . . it
This Permit is sufficient for the Removal (and Interment or Cremation)of a body[ ny part f 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'4104 was � 39/J
(Interment or r'r-T- .)
(Name of Cemetery, Cr
/4 L4
Section / Lot No. 02,/9— Grave No. I
fr
(Signed)
(Person in Charge)
Address ✓ � L
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.