Fish, George NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
air 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.
j Town, Village Registd//��((��. ...
Dist. No. J / unty....C�.ti.L.0 or City C���
(If city, give street addr� •
Name of deceasedf`"''"- Veteran
;i (If veteran, give name of War)
ingle, married, widowed, t� ���, •
Sex ' or divorced(write the word) ....�' Date of Death .., z( 2,. ....19 , 6...
Age `7 Years Months Days f Birthplace 0rA--> t
Cause of Death t
Certificate was signed by0 '. � M.D.
Address i / n-�-,
Place of Burial (or Removal e
(If body is to emp r•ly e , i in space r
Cemetery .. Date of Burial �% 197�.
(If body is to he temporari held, fill in space ter)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same appea 'ng to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav r cord d it in m Local Record with th above stated Registered Number, and on the bas• he of I HERE Y RANT A
FERMI
to
ij1 a .... . .........
(Name) �A a ess)
the to hold temporarily and the body
(Un e a or person_having charge of cope) (Inter, r ove, or otherwise dispose of (state how))
Dated . 19 ..1 (Signed)
h istrN�
This Per it is sufficient for the Removal (and Interment or Cremation)of a body to any pa t to l.lielo.1 cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS N 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 /rn" was 02 19 7�
(Interment or Cremati nd)
, Lt.u,„ o,
(Name of Ce6tery, Crematorium, etc.)
Section, ' ' 1f' Lot No. Grave No.
(Signed)
(Per on in Charge)
A •
Address J S ,rlrz"tx,( &,) I
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.