Cunningham, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
QF 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Q 2—
J t Town, Village4....a.t...--z.4.--toRegistered No. /�,�Dist. No (' i County !/�' or City 23 / l
'' ,, `` r (If city, give street address)
Name of deceased -{; . . _ eteran kt-)
(If veteran, give name of War)
4
Single, married, widowed, J ..--
Sex : . or divorced (write the word) Date of Death '`—"' " c9 19 6
Age (i Years. Months Days Birthplace
Cause of-Death `14.4--e-- 10- 41--'
-
Certificate was signed 172 M.D.
Address .. ..a. ,..
Place of Burial (or Removal) �,� t.A� 61 .s. .
...
(If body is to be temtrI held, in ftppce lat
Cemetery -._ .Date of Burial / - 19 6 J
(If body is to he temporarily held, fill In spa 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 R c d
with the above stated Registered
Numb and on the is thereof I HEREBY GRANT A PERMIT ' ' 2' - -'
11/ 17
.
�A � l �w (N (Address) l
the V - .A--' to hold temporarily nd the body
(U ertaker or perso;�havm charge of co se) (Inter,remo , or otbe e dispose of [state howl)
Dated 1. -1) 0.L- CP 19.. ..3 (Signed) .,
ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to a y 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, 82) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS QR
CREMATIONS ARE MADE
Date o was Q• Z E.
19_46
(Interment or Cremation)
(N a of Cemetery, Crematorium, etc.)
Section f Lot No. 4-3Grave No"' t
(Sigi3l 4a..4)•
(Perso n Charge) /
1:714-
•
Address' _0 Q • q-cNt ( a 0 —
Person in charge must return this Permit o 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 Dis-
trict 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 SNOT 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.