Stone, Mary 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,
Viltage, 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 Regt To. tJ
Dist. No. .0 , County W 6 or City �a
(If city, give street addr7
Name of deceased ?JAM. - Veteran ((((((��JJ
(If veteran, give name of War)
Single, married widowed,
Se or divorced(write the word) Date of Death Y / 19 ‘_
Age Ye firs Mont Days Birthplace ),Q,: re
Cause of Death .- .,/� . '
Certificate was signed by ./ . M.D.
Address � `',14&--6 '7C-7
Place of Burial (or Removal) "r "
(If body is to be totrrarily held., l in space ter
Cemetery ( A.---,a,-.....(...,(,�...c.,t.�.'... .... . . . Date of Burial � Z�-/ 19.7
(If body is to he temporarily held, fill in space ter)
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, haz,Ocorded it in my Local Record with he above stated Registered Number, and on the basi h reo HEREBY A
PERMIT �l_ �
.
( ame) _ (AdaressS
ty
to
.k(
the to hold temporarily and ....i ;.t. .. the body
(Under r o person having charge of corpe) er, remove, or otherwise dispose of (state how))
.
Dated ... C , 1 19 ... ..1 ,.... (Signed) .
ar
This Permit is sufficient for the Removal (and Interment or Cremation)of a bod any part o t e -ubject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
FOItM 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 P)t-74- %`'"' was ��.� // 19
(Interment or Geewwsion)
(Name of Cemetery, CEVIM.Wit4TIT
Section v Lot No. Grave No. 1=;Z 5
. ° ',. l�y;�. •
(Signed)
(Person in Charge)
Address a j
Person in charge must return this Permit to the Reg' t r
of his District within SEVEN (7) DAYS from above date.
person is in charge, the FUNERAL DIRECTOR or UNDE
TAKER MUST SIGN ABOVE STATEMENT, write across t
face of the Permit the words "No person in charge,"
FILE PERMIT WITHIN THREE (3) DAYS with the Regist
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE:A
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.