Dearstyne, Karen NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
�." ' This Permit can be signed only by the Local Registrar (Deputy or subregiscrar)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.
Town, Village i Regis red No.
Dist. No. ,�-76' / ' County .-."(,'61)- Eti i(- or City *�, e_.-,.c.-...',- - --17 41 . .
(If city, give street ad&ess)
Name of deceased (M-::f�. ' j 4- 4' 'x,-z- Veteran
•
(If veteran, give name of War)
Single, married, widowed, '.-z
Sex --F�E:-y 4c-L�_ or divorced (write the word) ..11'. -4- r-- -- Date of Death . 4--�f e 19 7-S
Age �`' Yea7v M the Days Birthplace g
Cause of Death T k`� CJ` ^ � "f
Certificate was signed by ..... ....-..... f�.•'''--j. i M.D.
Address - 5` 11 ,..t .Az ,L.,, - L, .-/
Place of Burial (or Removal)) ) A� E '--r-&-,-; 1�- `. ..,-
(If body is to be/amporarily held, fif)'}in spac dater) "
C -
Cemetery ; .rrl s k<c� ....... �_�x. , Date of Burial / 19 ,25— •
(If body is to he temporarily held, fill in spacelater)
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 tecorded it in m Local Recoil with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT /
to �_/14 , di 'IS `... ?`r:ntia 41 :�/.Lt_-a —-A.. A:: Q . t i '
/ r (Name) ` (Address)
the y"i to hold temporarily and 26tt.- the body
(Und [ r or erso-g having charge of co,tpse) (Inter, remo r otherwise dis ose of (state how))
Dated ,. 4�12.k- ,-. 19 l.5 (Signed) j am, t1'>e
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part he 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.
F'O12M VS. 61. (RFV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date or,47'Z
was d 7 19 76
(Interment or )
Y -�`z✓'y2�
(Name of Cemetery, cr,aaterrerfum,etc r'^
Section a Lot No. �` Grave No. /
(Signed)
(Person in Charge)
Address /
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," apd.
FILE PERMIT WITHIN THREE (3) DAYS with the Regjs %er
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.