Swartz, Theodore NEW YORK STATE DEPARTMENT OF HEALTH ,
OFFICIAL BURIAL (OR REMOVAL) PERMIT .
tar 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, Village ( -/' Registered No.
Dist. No.� c- / county !N Ch or City �✓. F Y`��-
c" (If city, give street address
Name of deceased / - ° . !4,z-4z Veteran �-
DD (If veteran, give name of War)
Single, •
married, widowed, n
Sex
or divorced (write the word) `�/I �-' Date of Deathfi7t 1 19 7‘•
Age G; Years Months ays Birthplace ,.,_ ,,,�.G!- -4--
Cause of Death .. . . . ,� �t t �
Certificate was signed by CL l.:G f M.D.
Address .Z - (1,..4 ...-
Place of Burial (or Removal) .... . • J.0 X) ` A(
(If body is to be to aril}*he d (ill'in space ater)
Cemetery -u.1..7..... ..1 Q�-ram Date of Burial �..' 19A
(If body is to he temporarily hel , fill in space ter)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, 'fte�l examination, the
same appearing_to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my cal Record with the ove stated Registered Number, and on the basis thereof I HE EBY GRANT A
PERMIT --%' 1
rL
(N e) 1) �— (Address)
the ` w to hold temporarily and �L f the body
(Underta or person having charge of corpse) (Inter,r e, or oterrwtse isspoose�`�of (state how))
Dated 19 .f...(� (Signed) •oca q it a
motr
This Per t is sufficient for the Removal (and Interment or Cremation)of a body to any p 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. (R16V• 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
l
Date f ,, 0!Ylij_k-92' was 2L' 19_G
(Interment or Cremat' n)
-72
(Name of Cemetery, C.ematooiurm,.e-te.)...,_- _.
Section l'' � t No 1- rave No.
•
r" , 4K 1 i Z -yt
(Signed) ----"
7 (Person in Charge)
Address /
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.