Fitzimmons, Richard Form V&6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit tan 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 CERT/IFLCATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Regis • • No. ` _ _.. ._
ll Village e- �,/4
Dist. No............./Coun ....d! . .».............. ...h._ or City +
(If city, give street addres
Name of deceased...... ... --('�4 �. . ........0---;?,-,Q4-eicbe-krty--41 ° �'r, Single, married, wido d, (If veteran, g' name of w.r)
Sex ' `\ Color kl.� or divorced (waste the word) Date of E '• 1
it/
Age.,a°� t1"� Years Months Days Birthplace ' •. .••
Cause of Death / -4-1LA-'J`k- 4
Certificate was signed V ' '! 4 •• M.D.
Address f 'z'^'' �}
�� �t �9"l.11,�(�u�s%`"�... � 1
Place of Buria (or Removal).... . :.C�?::LR.9:a.4�,,,,... .. ' _
(If body is to be p rily fll �space ga to
Z� 1 � ,. a �-' )i, 19�.._-)
Cemetery... � ��� Date of Burial ( Q
(If body is to be temporarily held, fill irYspace later)
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 s d Registered
Nu on basis basisrjof I HEREBY GRANT A PERMIT
_�} _ ,lN dress)
the `-'G'r _ to hold temporarily .nd r the body.
(U rtak&r person having charge of corpse) (Inter,remove,or otherw1 disoo a of[state how])
Dated ••�.. ii 19..t- I (Signed) > x '- 'L' ,
a1 Registrar d
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (wtbject 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 SEXTUN OR PERSON IN CHARGE OF
PREMISES ON WIICH INTERMENTS OR CREMATIONS
ARE MADE
i
Date of �Y'" +-»^4.-7.. was ale../ / d 19 6,-.1
Interment or Cremation)
(Name if emetery, Crematorium, etc.)
?41-
Section Lot No. 5 Grave No.
,,,4 ,,,,„
(Si ed) - / ,6" o
o�---e
(Person in charge 4
Address f). (j
1 G G 9
�,
GL>,
l
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.