De Witt, Victor 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.
•..
ARt2tte7o. 2223
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Dist. No..a.6 C) i i„ Coun . ZVO..4.4,. ..-L. Tovm, Villa 2
or City. ' .‘z., • / .,
i (If cAgit,e e t ddress)
/ -_.z."
Name of deceased ....L24.„4,./0... ?? •'c ,(4.. W,A.dt( Veteran
(If veteran, give name of War)
, Single, married, widowed, .„,.t"z44
Sex("2"... ce---' or divorced (write th word) ... -1/. . C Date of Death) C-- (''' 19
Age / /Yrars 1,)Azil:mth yp Birthplace.
,
Cause of Death '/
,e
Certificate was sign .y&_ , ,i/.erk7.4 P M.D.
Address .r.d".
,44(,',...1
Place of Burial r Removal ,401• .‘. •
(If body is to be t porarily," .;.1" in spac'era .5
,..emetery Date of Burial 6- / 19
(If body is t e temporarily hel , fill in space ater)
The CE rIFIc ATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same ap caring to be COMPLETE, CORRE •T, AND SATISFACTORY AS.REQUIRED BY LAW, I have accepted the same for registra-
tion, ha recorded it in my Local Recur k;ith the a ve stated Regi tired Number, and on the basis thereof I HEREBY GRANT A
PERMI X 2_
Ile
t ,
..,
---:- • , ' (Na .,1 .-- ad ss5
..
the to hold temporarily and ' , the body
(Undertaker or pe on having charge of coi..p.se) Inter, remove, or otherwise dispose of (state how))
Dated 6''......,./..3 19 75 (Signed) .
2.11
This Permit is sufficient for the Removal (and Interment or Cremation)of a b to any Itaraaire t tr(asrubject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is r ired.
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 -t ' was // 19 7�
(Interment or Crem on)
(Name of Cem tery, Crematorium, etc.)
Section = /144 ( ' Lot No, ^r Grave No.'?"
(Signed) --''i
(Person in Charge)
Address 3 grritni, 41-€4ta ALL 4 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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit ..th.e..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.