Mallaney, Myrtle NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. I��)9
/ , , Town, Villas r �Cf(xl ste d No
Dist. No. JCG I County (,.�0 � / or City.... .. �
If city give street ad9res.$)
21{
Name of deceased .. Veteran (If vetera , give name of War)
Single, married, widowed, '`�2 (l ,---
Sex or divorced (write the word) ./...!./..atlit„.a- Date of Dea ' 7 19 ..2?.
Age ea -Months s e Birthplace ..,
Cause of De th .. lD.. .... . .
Certificate was signed by /11,, M.D.
Address .._<
Place of Burial (or ' : oval r( ' `',
(If body is to be t n• arily'he)er,j`il 1 n pace t
CemeteryQ„ Date of Burial lU 197r-
(If body is to he temporarily held, 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 REQU RED BY LAW, I have accepted the same for registra-
tion, have re orded in Local Record with the above stated Re s aced mbar, and on the basis thereof I HEREBY GRANT A
PER T t) S'7--(Name) / ct"61essj ,
the .. .. .. . . .. to hold temporarily and .... the body
(Underta er or pet on having charge of�rpse) (Inter, move, or otherw se dis ose of (state how))
Dated —�. 1�� (Signed)
?al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an part 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.
FOItM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date o was '�1,4)/
(Interment or-€rem—'
(Name of Cemetery, Crematorium,
le4(4‘1W>;ele
Section e-; - Lot No. -77/ Grave No. J
(Signed), -
( erson in Charge)
Ada _
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.