Massey, Baby Boy ri.gak Yd.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 Registered No— /-.:.--4----
Village t. ......67,_...a-
--
Dist. No- ---/ County....& e.-- -e-,-- or City --'' - (--/4g
(If eiy, give streeea
,—?dc%
Name of deceased V. tean • /
i S. gle, mitried widowed, ''f-4e*' • (If ' .'give name of War)
Sex -.16)-)/ Color '- r divorced (wnte the word).. -...-.,.-, .,.' .Da o ---
.....-
Age :?..,, Year Months '...... Days *rth e..,. .... -.
Cause of Death . i. --4-- 4- 6,./
7 •
Certificate was signed by......... ....4. .......‘.E../.. . / - ,,, M.D.
Address i--C- fL3,17.7__. ,A--""
Place of Burial (or Removal) --. , .......--,..-e_.,:,..„6„...4
(If body ir to be temporarily,beld,fill in space later) .Z4
_
Cemetery ts;.--------Cs:".a-a, ` ./` .------c-- — --- Date of rial -7— 1.... -
(If body is to be temporarily held,fill In space later)
The Certificate of Death containing th above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stpted Registered
NumKeryand op the basis thgrofiI HEREBY GRANT A PERMIT -- 1---' "7/1 y
ton.k--Y-'--s"----.--(J)-". 6(1. 4,1, •
.- , .....,- ..-..,,,N
the ' ---? L -/7"11a.gz- '.. - - --fil.. . .......--' to hold temp . and..... ...2N, e— --' CIO re )
-tile body.
(Undertaker or rump having charge,of corpse) * (Inter dispose of(state how))
Dated 7 64- ',zt 19.C.,.-F..e (Signed
./ Local Registrar
This Permit is sufficient for the Removal (and Interment or Crernati n) 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.
ENDORSEMENT OF SN'X'lUN OR PER )N IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date was- _c.` 19 6
(Interment or Cr tics)
•
(Name of Cemetery, Crematorium, etc.)
Section /,( " Lot No. Grave No.
•
(Signed) . - "\t-t� �'
(Person in charge)
Address d ,/ � �� u C� -
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re-
quired, under penalty, to report violations thereof.