Doty Sr, Valney NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
riir• 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�� gisteed
Town, Villa - ?..
Dist. No.��< j Couy... . . or Ci ,,• ••!.�`I (If cit give srea .ess)
same of deceased . ni,.._j
e•• Veteran 7.G -
(If veteran, give name of War)
ingle, married, widowed, LA-416144Pz-e
_ d' ,7or divorced (write the word) Date of Death .. 19 / �
Age gYe,�rs" / ...Months D s , - Birthplace
Cause of Death �,.1 "� `�l''s'�'�r
Certificate was signed by.....r.. a t`•
�t M.D.
)Address q
�-"
Place of Bun 1 (or Rem a
(If body is to e t mporaril a fi i spa act r
Cemetery ... Date of Burial Ch-- /e 197 5.
(II body is to e temporarily geld, fil in sp ace lat
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same Appearing to be ETE, CORREC , AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion ve recorded . in my ocal Recordwith the above stated Regi red Number, and on the basis thereof I HEREBY GRANT A
PE
iti '
to / j21.,,•Ir“E"- ..()NiEkk , -
(l1a ress
l't
L..'.(�the ' to hold temporarily and the body
(Undertaker or pe n having charge of corpse) (Interwove, or otherwise dispose of (state how))
Dated -- // 19 .7..c (Signed) l/l., a
lThis Permit is sufficient for the Removal (and Interment or Cremation)of a body to an�art of theSt�(subjeto 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 oft --r,'was 19 yam._.,
(Interment or Cratvet+^p)
(Name of Cemetery, C-r L.
Section Lot No. Grave No.
(Signed)
(Person in Charge)
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 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.