Roblee, George 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.
Registered No. MC-)
Town, Village
Dist. No................\ County ------k---="C—,'-i-\ or City C.---... .Q.,.: ::-.:-.)..... .-- -...-.—.
(If city, give street address)
--,
Name of deceased ..L.,.(-- G.--:\_c-€__ ,,.----\ -Q.,-,__ Veteran ..kj_ -i_)
(If veteran, give name of War)
Single, married, widowed, - ,
Sex \\-\(.2),C—C1-- or divorced (write the word) .\. ..c.:...L .LL...C.I. Date of Death ._;,,L.\_:.\ . )..4.. 19 7)
Age.71 Years Months Days Birthplace ---,' ---\c-\.1
„
Cause of Death \i,. -‘,.k5s, .,.X ---- ---C.IAA1P—LLN-------c, -..)
Certificate was signed by ., .., -.-v-,-,. ---2A--\ c,c...,„ M.D.
Address c-..—.s. ":, '-,-.....c,f-'—. '' 's, YZ
Place of Burial (or Removal) ' 1,,k i.„iv,
(If body is to be temporarily held, in space, later)
,..emetery A.
19. Date of Burial u.A4p ,-) --- -) r
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same 4ppearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
-:-- z--- _
("""' -"L\ ar.- •).....”' ••,,N. ,..c. ...,,,_
to T (Name) (- -(Adaress)
the .... . .C.. .' :7--.1---,,•" ---''' to hold temporarily and c.5---.. L.:-.1 the body
(Undertakeç or person*having charge of corpse) (Inter, remove, r othe ise dispose of (state how))
•-• -
Dated ‘f.'c,-.-L,.s.:C._. cx '-ik 19 --) )------ (Signed) .
, 1 rar
This Permit is sufficient for the Removal (and Interment or Cremation of a y to any part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Trans Permit (VS No. 62) is required.
FORM VS. 61. (ItKV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was k,vit '� 19
(Interment or Crema n)
dEA-' O ► Alt l A 4,1 �tli/ri.32 d3�
(Name of Ce ecery, Crematorium, etc.)
Section S' P 1) Lot No. (0 02.- Grave No. I
(Signed) (f � �� p'1
(P rson in Charge)
(� t 1l,, A" \/
Address b r cvf ..� / ;nv (Tau , Jv .
Person in charge must return this Permit to the Regi
of his District within SEVEN (7) DAYS from above date. If
person is in charge, the FUNERAL DIRECTOR or UND
TAKER MUST SIGN ABOVE STATEMENT, write acros
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Re ' r
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE S
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
TNAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.