Harrington, Alice NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregiscrar)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. /��
/� Town, Village RegisteredLN No.
Dist. No.4. 40/ County......Ze. Q '� or City vA.x�. rl d/f
/� (If city, give street addless) o
Name of deceased t • •... teran
(If veteran, give name of War)
Single, married, widowed, .
Sex or divorced (write the wor Date of Death .....Yf 192A
Age cle 7.......Years Months Days irthpleg -
Cause of Death . �. 7.
Certificate was signed by !! M.D.
Address 1 i" 17...
Place of Burial (or Removal) .... . / 440 y 4 •
(If body is to b porarily he fill i space later) (,(J
Cemetery ......... . Date of Burial .,.. « 197,J--
(If body is to porarily eld, f. ..�nill*Ipace lacer
The CERTIFICATE OF DEATH containing the above stated particula , 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 ecorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
6 7,7 ,,4 14 h •9....
to ress /
the to hold temporarily and the body
ndertaker or pers n having charge of cor se) (Inter, remove, o t erwise ispose of (state how))
Dated
i�L .l 19
7. (Signed)
''kcal isc�
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a par •th to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permif'(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 i a was // 19 7
(Interment or C-reelgriorr)-----
Y
(Ngime of Cemetery, G ,
Section Lot No. c // Grave No.
L
(Signe 441
(Person in Charge)
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.
a ,;
SEXTONS, FUNERAL DIRECTORS and UNDERTAKER
violating the law relative to the retumof permits are liable fo
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.