Shaw, Sarah 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.
Tbv Vilia a !Registered No.
/6 (,E_ -c-cam g 4 <_<_,
Dist. No. / County; or City
/ (If city, give reef address)
Name of deceased , -) fi1��(_.., \ --ea---�: Veteran
(If veteran, give name of War)
/ , Single, married, widowed, -�
Sex �/j Z=t � or divorced (write the word) �G� Date of Death`J4' , _: �
Age Years `3,l :Month Days Birthplace ��L k`
Cause of Death 4%��... :�':!.�/' ... .
e�� / /
Certificate was signed by�,E—' - h �� M.D.
Address.A'�'/2'✓/ / 9Fc/. c' , .,.�'`__„.'`'<..
- .
Place of Burial (or Removal) .. . ,, (,.�„c,;� -9� CIA.-t —n''v
(If body is to be temporarily held, )ill in a e l r �`
Cemetery Ley—�l-v--e rJ. , ( - ate'df Burial -7 Ai 19
(If body is to he temporarily held, fill i space later),7
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same apppe ing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I ve accepted the same for registra-
tion, hay ecorded it in my Local Record with the above stated Registered Number, and on th 's thereof I EREBY ANT A
PERMIT / ';
(Name) i -; (Address)
the (to � to hold temporarily d ,/�'�'�` cam, th ody
(Undertaker per on having harge of cof�pse) - (I ve, ise ispo of tot ow) r
Dated .. :1-- 1 19..../.,,5 (Signed) 'L-' 1--( -4--(—
`` Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local ceme ry or
other regulations), unless removal is by common carrier, in which case a Transit Permit(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 c n-e-n, was �/7Y 19 'S
(Interment or Cremati n)
p 624')9 PoC P jJ3
(Name of Cemet ry, Crematorium, etc.) O
Section Oil U a Ieit Lot No. Grave No.
4+
(Signed) ( �SLCil-�h
(Person in Charge)�
Address 3 ��'T ,I ; /r c /t
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 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.