Fleming, Walter 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,
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.
own, Village Registered No. 1.
Dist. No...5 L°!// County f�� .. ..... . or City ....
t (If city, give street address)
Name of deceased 4(..C1.-C / eteran
(If veteran, giv name of War)
5'_� Single,divorced
married, a widowed, . ..� //
Sex or vorced write the wor Date of Death � �' �1`' 19 �,1.�
Age , - 90 Years .Months Y Days irthplace
Cause of Death
d
Certificate was signed by r.... M.D.
Address . . , .2< ,
Place of Buri 1 (or Removal) .... O.
(If body is to a em rattly hold, fi I in space later _
Cemete .. .. . ... .. ... ... ate of Burial /`Z.771 O 19 7.�
(If bodyis to e t por -e , it in space later)
The CERTIFICATE O DEATH containing the above stated particula , 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, hav recorded it in my al Record with the above
, stated gistered N mber, and on the as' thereof
fI�HER BY GRANT A
PERM 1` Cam'% -G.e... ,�tt`"""- /er,� . ........ 1� j
to ....
Na A res
k - ' . .:..:A.... . to hold temp rarily and body
Dated(Undert oLper having charge f corpse) (Inter, remove, or' therw�ty�e d' of (state how))
Y/ �— C rj 19 ... �I jLc. �°'
J (Signed)
Deal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an art 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.
FORM VS. 61. (Rl V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of Drvt-2r-'rn�7n 1— was kbr..24 () 197
(Interment or Cremation)
j/i;
(Name of C metery, Crematorium, etc.) l
Section g P L/ Lot No. ei Grave No.
(Signed)
(Person in Charge)
Address �12�f ) ,� � � Y
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 UND I-
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.