Clark, Ella NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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.
�j�/2 Town, Village1/eie,i6.1;eg=lo.
lDist. No0 �( / County "t-'G�f.17.A �la/ or City
er � (If city, give street addr s)
Name of deceased ...�....�� if L/i 15- Veteran —
(If ve ran, give name of War)
Single, married, widowed,
S ..... or divorced (write the word) . ,r�e Date of DeaU{` 1 /�7 S_
Age .Years Months Days Birthplace
Cause of Death
Certificate was signed by .. .. I .... . M.D.
Address ��:E-�.
)77
Place of Burial (or Removal �
(If body is to be porar1 y held, n spac r) _
Cemetery . # . .......... Date of Burial J.�..�c�/e) 19.��.,(
(If body is to he temporarily eld, ' in space ater)
The CERTIFICATE OF ►rATH containing the a ove stated particulars, having been presented to me, after careful examination,the
same Appearing to be CO PLE E, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, h44_ersO
it in my L al Record with e above stated Registered Number, and the basi thereof
I HE
GRANT A
PERMIT toV
(Na e)✓ ' yi;'?(Address)
the ... to hold temporarily and the body
aving charge of c p5.e) (Inter, remove or otherwise dispose of (state how))
Dated2.i 19 .... (Signed)
1�Sl�strN
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part th to 1 cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS N . 62) is required.
FOItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date off as J--/V G i9i'6
(Intermentoa rrertatioalr
(Name of Cemetery, C a---iti —se `
Section Lot No. Grave No. —
(Signed) ''?
(Person in Charge)
Address -0j "Z '
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 Registrat,
of District in which cemetery is located. '#: .
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERSg
violating the law relative to the return of permits are liable
a penalty of NOT LESS THAN FIVE DOLLARS NOR MOR
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. Th'"
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.