Suprenant, Elizabeth 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,
Vilrage, or City) in which the death occurred after the FILING and acceptance o a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN D RABLE BLACK INK.
Town, Villa Re ' ered . .i/y
Dist. Nor. U c)( aunt or City •••••yam
(If city";give street address) V
Name of d: :s Veteran......<!���
(If veteran, give name of War)
Single, married, widowed, /)
Sex / • - or divorced (write the word) cQ'/.(AX.. . Date of De .. "3� 19
Age.. ... .. Years .Months ...... ` Days Birthplace
Caus. •f Beath
Certificate was signed by... .• . .. M.D.
Address ,
Place of Buri (or Remo ) '
.
(If body is to b to poran ..
ly 1 (i r. space later ) c
Cemetery ... ... . _...,........... ,-(LYt,t Date of Burial ...•,,,5 19 2,
(If body is to he temporarihy held, ill in space later)
The CERTIFICATE OF DEATH taining the above stated particulars, having been presented to me, after careful examination,the
same pearing to be COMPLET .ORRECT, AND SATISFACTORY 'REQUIRED BY LAW, I have accepted the same for registra-
tion, ve recorded it ' my Loc 1 Record with the abov stated Re 's red Number, and on the basis thereof I HEREBY GRANT A
PER&
a e) i t�. jess) -.. L.,..7:
th to hold temporarily and .... the body
(Undertaker or perso having charge of corpse) (fa •, remove, or othersvtse/dispn'se of (state how))
Dated — it19 2. .. (Signed) /! '' ../.., i=% ... ,
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 4A was < 7-e:e1L4( 19 7C
(Interment or Cremation)
(Name of Cemerer , Crematorium, etc.)
' r
Section `` `--•- Lot No. Grave No.
'41
(Signed) L- "` t�2.- iti
(Person in Charge)
>
Address _ )�
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. Ifno
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.