Shaffer, Mildred Form VS.SL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 CERTIFJcATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._ bb
Village
Dist. No 3296 County Oneida or City Utica State Hospital
(If city, give street address)
Name of deceased Mildred Shaffer Veteran No
(l( veteran. give name of War)
Single, married, widowed,
sex FemalEtolor White or divorced (wnte the word) Married Date of Death. rokl...6, 19 62
Age 74 Years 6 Months 1.......»...Days Birthplace....Ne......`.-1 ox'
ls
Cause of Death Broncho—Pneumonia
Certificate was signed by Robert E, O' Toole, M.D.
Address....12. .3 CoQ.r't Streg.t., Ut -cc' ,. NQw Rork
Place of Burial (or Removal) L;�e='".? tF=' I!. N�""' tic ) I i--
(If body is to be temporarily held,fill in■papflater)
Cemetery 1'/^".------t-' 'tw tr L—(=--mt=1-�'2 `") Date of Burial . .-Irz�.h-- d' 19‘4—
(If body is to be temporarily held, fill in apace later) 1
The Certificate of Death containing the 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 stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT 1
to /2 -1--- ✓J G l-2 ,S 712--i .- / ct.,.._•4.,s__ i.-.,/1_; '
rti/i !a (Name) (Address)
the.... to hold temporarily and the body.
(Undertaker or person having charge of corpse) (Inter, remove,or otherwise dispose of[state how])
Dated 19 (Signed) 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEBMENTS OR CREIMATIONS
ARE MADE
L
Date of f 2 2( 19 e' /
(Interment or Creit �)
A Cc 7: C /C �i t
(Name of Cemetery, Crematorium, etc.
Section Lot No. Grave No.
r ;, l� ; / fir
(signed) ii� �! , 1 ,
(Person in charge)
Address ` !�C / Z�/`L i ✓�� .
jr;17
Person in charge waist 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 fiords
"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.