Workman, Dustin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or 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.
,� Town',ViH a gistered No.
Dist. No. /�// County fit. --a /(,)''er -h-i..11441-1-44/eteran
or City/� , (If city, give st et address)
Name of deceased ✓`1, 2 -i. `L'
(If veteran, give name of War)
'��� Single, married, widowed, �, c `
Sex d1i or divorced(write the word) ate of Dea f�'` �' . 9 41..
Age Years Months 8 4,._,...
• ,( Days Birthplace s
Cause of Death .�t!e z'xx:t.f-r dt e. ---1 4 sx2,z-.,; /59
Certificate was signed byy.. (.1 „ -err V M.D.
Address = :.. ^ `?G -�-4= 72
..
Place of Burial or Removal) f
(If body is to be temporarily held, i)'i space later 4nal4 /Qt./
•• •
Cemetery / `:7. 7. te o 19The CERTIFICATE OF DEATH containing the aboe stated p rticularving been presented to me,aftereful examination,the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY L W, I have accepted the same for registra-
tion, have ecorded it 1 my Local Recor. •ith the above stated Registered Nu er, and n t pa basis thereof HER B GRANT A
PERMIT
(Nai (Address
the �% t'emporarily and ... '�• the dy
(Un ert r r person havi ,'�harge of corpse) �(Int , re ove or s is (st a ho ))
Dated a.7 19 .... (Signed) C-4- !
Local Registrar
This Permit is fficient for the Removal (and Interment or Cremation)of a body to any part of 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.
FO'ItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
--yy d;
Date of r,JL i n , t was .i.cf% / 19
(Interment or Cremation')
(Name of Clmetery, Crematorium, etc.)
Section 4+'L,�. ��/ Lot No.,•22. y1cL1 i Grave No.
(Signed)
(Pe on in Charge)
-]
Address � �41 • ��, ,�ck. ( , , 1,
i
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.