Harris, Marshall NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ra' 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 DURABLE BLACK INK. �_�/
Town, Village gie:ceAgiste No.Dist. No. a f>/ County o Citye 4
(If city, give street addrs
Name of deceasedL .. ... ZAu_. -_- Veteran
(If veteran, give name of War)
Single, married, dowed, '
Sex or divorced (write the word) Date of Dea (.e` P'6�. 19 73
Age.. .. Years. .. Mon s Days, Birthpl e ie '
Cause of Death
Certificate was signed by M.D.
Address .46 GL .. t c a CL-u-T 16y
Place of Burial (or Removal) .. . ..
(If body is to be to ,porarily e`d, (ill ''a- .ace ester 0j
Cemeteryo„) .' 0 ' • ' A Date of Burial C.f 1- 19 7.3
(If body is is to be tempo arily Id, fill in s race later)
The CERTIFICATE 4 F 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 r c rded it in my Loc Record with the a eve stated Regi tared Number, and on the basis thereo I HEREBY GRANT A
PERMITto ei--le.., k ict-KL4.4 /
am Aids5
the .., :,'_ to hold temporarily and the body
(Under r oropersohjiaving charge of corp (Inte r move, or otherwise %G.se dispose of (state how))
Dated Or .19 (Signed) Rg .►
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an art of the State (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 o#`_ "` .% �t-�4 ;as L �` � t7 19 ,s
(Interment/or €ee 1%464al(Name of Cemetery, C-reetrivm,.._c .)
Section Lot No. Grave No.
--- fl.-14_ -
(Signed ,
(Person in Charge)
r ' •'•
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 UN ,
TAKER MUST SIGN ABOVE STATEMENT, write across
face of the Permit the words, "No person in charge," a ,"
FILE PERMIT WITHIN THREE (3) DAYS with the Registr
of District in which cemetery is located.
SEXTONS,FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are habit 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.