Vicha, Helen NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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. ...2 �/
/� / Town, Village 4' Re
giste _/
Dist. No,_,) �C�/ C my 4l 0�4i-it, or City ��'� b� /'C/
l� . o _ (If city, give street address)/
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Name of deceased . KI-"C- 2.-- Veteran
(If veteran, give name of War)
Single, married, widowed, /, / / /
Se c���J �'r'?�l // or divorced (write the word) w.J(-.'f4 1 -- Date of Death 6 17 19 ...,7E
Age 7 2-- Years Months °F Da s Birthplace u -
Cause of Death (a" � `' (`J//
Certificate was signe by M.D.
Address a�..s� a�/1 1d4 P c.,...tj<. -�
Place of Burial (or Removal 1t< Q.Qtn.X�
(If body is to bet orarily held, i irj�space Later y
Cemetery dor A x ° Date of Burial,% 'l 7-- 19..✓... .
(If body is to be temporarily held, fill i space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ha recorded i i my Lo 1 Record with the above::,06..,e__ stated Registered Number, and on e bas4 ' 2
ERE Y GRANT A
FERMI
07.
dr •
the to hold temporarily the dy
(Under Sr or erson having charge of corpse) r, re or rw a dispose of (state how))
Dated (/ 19 74 (Signed) t
Local Registrar
This P mit 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 �� �,x- YL / was j 197e.
(Interment or Cremation)
(Name of Cemetery, CEcma�oriun,--e*=`
J"
Section :�5.: Lot No. �L Grave No.
(Signed) ,.° - � ���-PZ��
(Person in Charge)
( '
eef'
Addresses _/�
Person in charge must return this Permit to the Re 's r
of his District within SEVEN (7) DAYS from above date o
person is in charge, the FUNERAL' DIRECTOR or UND
go
TAKER MUST SIGN ABOVE STATEMENT, write across e
face of the Permit the words "No!person in charge,' d
FILE PERMIT WITHIN THREE (3) DAYS with the Regi r
of District in which cemetery is located.
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SEXTONS, FUNERAL DIRECTORS and UNDERTAK2S 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.