Dupell, James 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,
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, Vill tere No.s �!
...
Dist. No.--�6'a' . County `��ut'r + i or City � Ll
(If cit , give street addres3,)/
Name of deceased ,. ,�.. .. ... Veteran ... . Gf
(If teran, give name of War)
Single, married, widowed,
Sex ., . or divorced (write the word) , Date of Dea 19 7
Age 3. .. e rs....1 . the Days birthplace.......c.
Cause of Death / .�.. l . . ! ... !s0 , '/:
Certificate was signed b r � • M.D.
Y ...^. ..:. .. .......... . " I_
Address O►.
Place of Bur' or Remo al) ... , ,G(.t
(If body is to a mporanl eld fit in
terj
Cemetery Date of Burial /vL 19 2�
(I ody is to a temporarily held, fill in space later)r
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,„,1 QUIRED BY LAW, I have accepted the same for registra-
tionto , h e recorded it i Local Rec d with the above stated RegisTed Number, and on the basis thereof I HEREBY GRANT A
PER jT �jj,,
. ,
(Name) . (. _Ls
the to hold temporarily and the body
(Un ertaker or P
on having charge (In remove or otherwise dispose of (state how))
e of cors
Dated / 19 (Signed)
fiegoca
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State su ' t 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. (RI V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
/,
Date of s was //"'Z 19
(Interment or 6cernation)
id4"- -"' 4' k-1-4-14/t-
(Name of Cemetery, t-t Vim, etc.)
/4e'di°44-e1Q.'-bi•-'
Section / Lot No. 7,1"Grave No.
(Signed)
(Person in Charge)
Address X-' j '� L a...._. C.-4.'-lit
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) 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 Distr1ct 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.