Buckbee, Lena 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. / a&
Registered No.
Dist. No. 42,ml County..�� 'er orToa Cityww;-il rlte e- Ln�g�G4i Ar.7
LEN A WA,
R� (If city, give street address)
Name of deceased /� //tom Veteran (If veceran, give/name of War) _
Sex � (/�./v3��'F Sior divorcedr( the word �'"D Date of Death 4c `� 19
write )
Age 9°°,11 Years nths Days Birthplace y'
Cause of Death ....>-.
Certificate was signed by R ry ppr ,. %._/G F tr M.D.
Address —Ze Fr W. ''Z'
' �ieV
Place of Burial (or oval T f/ (�
(If body is to be ter held,-.Li 1 nza�htxrE �ry� 7 �+ i® J
Cemetery .. T GGG��� /�, to of Burial e • 19�
(If body is to he temporarily held, l in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, h tng 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 recor d it in my ord with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT 7?r,4 A lie.8./ / U a5 / 7, 444 145 c-740L — V'4Z JX s
to
the A IV, '-� 4,/r4F to hold temporarily - / /V/ the 104dy
(Undertaker r vi barge of c se) r removh, or riQ-m�i a of (state how)
Dated .. (�i 19 .......fie (Signed) ..
Loce;Registrar
This Permit is sufficient or the Remov 1 (and Interment or Cremation o . body to any part of t..e State (subject to to emetery or
other regulations), unless removal is by common carrier, in which case a Tra sit Permit(VS No. 62) is required.
FORM VS. 61. (RRV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was / /' 6 19 —
(Interment or -
d (Name of Cemetery, C- _•^-^•^ � � 1
Section Lot No. Grave No.
\ 4i0
t
(Si:' ed) a �
(Person in Charge)
ti
Address le/et/
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 retum'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.
'