Chesto, Frank 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.
7/J Town, Village) f�'� R st d No.
Dist. No. Co/ County vv��/ or City �� .�
(If city, give street addhss)
Name of deceased 1244_4,4 Veteran
(If vet ran, give name of War)
Sin , married, widowed, ,
Sex �, Q..�,t or 'vorced (write the word) �1-�l/1.4--�,Li Date of Death L/ 7 19 74 °
Age .J'. Years Mo the ... v D� Birth lace.... . `
Cause of Death .....(La -
Certificate was signed by •
M.D.
L1 t7 .
Address �L '/�••/•.•. ....GJ
Place of Burial (or Removal
(If body is to b empo he (i in space ester
Cemetery .... Date of Burial -c/-'7( 19 7s
(If body is to be temporaril eld, fill in space later)
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 orded it in my Loca Record with th hove stated Registered Number, and on the basi hereof I HER
GRANT A
PERMITe.,/,
'T.
2n .� ( ame) (Ad ress)
the .. to hold temporarily and .... body
(Underta r or p�er,son having charge of cyyri�pps�}— (Inter, remov r other t e dis ose of (state how))
Dated .t /u 19 7,5 (Signed) ...
L l r
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part the State (subject t4 0 1 cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
FORM VS. 61. (RI'V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of S1iikt was/7 Q/x. 12: 4) 19 7 S
(Interment or Cremation)
Cam- Li
(Name o Cemetery, Crematorium, etc.)
Section 'J I Jam/ Lot No. (0 3 Grave No. c
S
(Signed)
(Person in Charge)
/
Address 1 'L r1% ' 11% 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," a d
FILE PERMIT WITHIN THREE (3) DAYS with the Res'rer
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liabl
a penalty of NOT LESS THAN FIVE DOLLARS NOR MO
4
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. pit
law will be enforced. Local Registrars are required, un
penalty, to report violations thereof.