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Cottrell, Walton NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT Ear 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. ,,,, .(^?� // ,, Town, Villa Lr//�J�M ,�RBgrst N . Dist. No �cl/ Count/120( 4,k71,..1 or City tni (If city, give st(eet a dte Cc atde Name of deceased ZU.ale&-v, Veterany — 6em./_, _ (If veteran, give name of War) Single, married, widowed, Sex4.„,k,___ or divorced (write the word . .. . Date of Death ...,. .nA' '2 19AgeYe s s Bi '�lilace �/,( ' Y Cause of Death «< Certificate was s'gn d by M.D. Address Place of Burial (If body is to b t m raril ''fie d (il / spa at ). l Cemetery � Date of Burial � ^9 197 j-- (If body is to temporary y he d, fill in space later) i The CERTIFICATE OF DEATH containing the ab ve stated particulars, having been presented to me, after careful examination,the same ' g to be COMPLETE, CORRECT, A SATISFACTORY AS '- RED BY LAW, I have accepted the same for registra- tion ave rec ded it in y ocal Record with a above stated Registe t•umber, and o basis thereof I HEREBY GRANT A PE M[ " f P F (Name) �"� (A dressy the ... to hold temporarily and ...,. . �:, the body ndertaker or person having-charge of core e) (Int _ , ave, • # •the°!/�j a di ose of (state how)) Dated rl�--^ 19 ,2 5 (Signed) e • � Local Registrar This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any 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. 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 v c�/ 19 7-6 (Interment or Cam_ (Name of Cemetery, C atonum,eta.')--- //,47-7 O J Section Lot No.` Grave No. 4-11. grad) (Person in Charge) Address v � -1/47'2 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.