Jalet, John NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far' 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. �rl
Town, Village _"R"egistered No. �1
Dist. No. ..... County.�J...D or City C. �C
(If city, give street address)
Name of deceased m...... . Veteran ... .CD
(If veteran, give name of War)
Single, married, widowed, •
Sex \C11e�QVc or divorced (write the word) ...m`L� Date of Death_ .Q,XCI c \......19 :15...
Age r14) Years .� _Months Days _ Birthplace �,� CAf�
Cause of Death
Certificate was signed by M.D.
Address Q. .. Vv—S
Place of Burial (or Removal ti`(�, �.
.. .... O n.
(If body is to a temporarily held, (ill in space la r)
Cemetery �sli� g.,�, Date of Burial Di 19 1 S�
(If body is to be temporari held, fill in space ater)
The CERTIFICATE OF 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 recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
P flE .,Q4
( �
(Na e) ,,_p
the V.M\16.St1,: ,9 to hold temporarily and CC--�`�",7--L the body
(Under ker or person having charge of corp� ( ter, remove, or otherwise dispose of (state how))
Dated c,...., Q� 19 �, (Signed)
oc-This Permit is sufficient for the Removal (and Interment or Cremation)of a body to ny parL'of t..c State s ct to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Per it(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 of 2tc---,,,,„74- was 19 7-5-
(Interment or Cr ation) 1
P.Ctfi,«7/)[JYI.OiC,P �-k��' �.
(Name of Uemetery, Crematorium, ;cc.)
Section.,�(0 I Lot No. J ' Grave No. //
(Signed)
(P rson in Charge)
Address 3 SC(/ -9 ✓��
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 retumof 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.