Witherell, Muriel NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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 C RTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /�
/� dj
Regtst try K�
�i / � ,' Town, Village C
Dist. No. J 46 f County - --6'A-'/ or City
�J (If city, give street addres
Name of deceased /' �L / �. �1,�. ' Veteran '
(If veteran, give name of War)
Single, married, widowed, 1
Sex or divorced (write the word) .� C(..^-2-eI Date of Death ... .. 19
Age `1� Years .Months Days Birthplace ,
Cause of Death '
Certificate was signed by ......... :A,-.V.-----X..4.„ s,... M.D.
Address . k= .2-'"`v
' Al- .
Place of Burial (or Removal ...� U -c ,c.
(If body is ta'* t mpor he d,' n�sp later) d i
Cemetery .. � ....._. �.�.-.. �.�?/2� Date of Burial .... ,2_ 19, ,.
(If body is to he tempdrarily he d, fill in spa later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after areful examination, the.
same 3,ppearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav recorded it in my Local Record with the abo stated Registered umber, and 4 the bays thereof I
HEREBY
GRANT T A
PERMIT ( // / a/ -4 jet' kc
1C�r� L
ame) (A dress)the ��� 6,a '-^'• to hold temporarily and the body
(Uri ekf or person having charge of co se) (, , remove, or otherwise dispose of (state how))
DatedL 19 .. (Signed) • oci..... .
•
This Permit i s fficient for the Removal (and Interment or Cremation)of a body ny part of the State�ect 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
ate
Date of was 9/
(Interment motion)
C7/e". /4-4,-/izar7s .
(Name of Cemetery, Crailiailitkifarett^�
Section Lot No. Grave No.
(Signed)
(Person in Charge)
Address 1"
• Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date.tIfSp
person is in charge, the FUNERAL DIRECTOR or UNBito
TAKER MUST SIGN ABOVE STATEMENT, write across t
face of the Permit the words "No peason in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Regis
of District in which cemetery is located.
r
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.