Loveland, Margaret NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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. ` e,
Town, Village ( / Registere No.
Dist. No. ,J /C' County t�((_ 1�F. -&.. or City Gi..l !..., ��'
`2;� ��.�::x.,.�.... �
(If city, give street address)
Name of deceased ` ..I�.�.GS.i t !, L?1 Y'Z.-f*;t,� x-<f. Veteran
(If veteran, give name of War)
Li (Sin le, married, widowed,
Sei m-� or divorced (write the word) CU '- C�2-
....... <Lc Date of Death .... 19 7i/
Age Yea Mont D s Birthplace ., 0' t.
Cause of Deat� G(-�c. .. ,a.4;.... rA,--r(.1, y P' -"-- • p
Certificate was signed by � c ,-?`� � -4_ .... eru. M.D.27Le �,ch.}A4 r ,
Address '..�. _. - e'l-/
Place of Burial or Removal ....�.,t„ :,�, /-(... . �ti
(If bodyis to bet m oraril hq�d a n sp a ate /'� �_
Cemetry - y v/Q--(x)-� ,(1. Date of Burial l C� 2 19 �
(If body is to he temporarily held, fill in spa 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 yecerded it in my I,docal Record with e above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT ,'�/ j i, I
(Name) . (Address}
the !L?:c., ,:t, �=1- to hold temporarily and `-----{-tom.- 4- the body
(Underc ker of per,on,having charge of corpse)_ (Inter, r ove, or o erwis isp o (state how))
Dated ‘-t- 1. 19 ..../ ......... (Signed) w
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any p rt 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. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
r_e/
Date of as
7t ,
(Interment or Gsott)
`{
(Name off Cemetery, Cosaiiatotiun, L«.y
t,/ - e'LAV/J
Section Lot No. /7" Grave No. �-
Si ed " a - u
r (Person in Charge)
\� j ?„,,
Address
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.