Stephenson, Frances ..--- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Re:•. ation District (Town,
Vilfage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND CO • ETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
:
Dist. No. ../4---‘6/ County (69.(6/v----"--) or cir • - - A-(,...z.,..4.g
(
Town, Yllage Re: , erscl No.city, give street a ess)
Name of deceased - 44-41---c-1-42 --4 - v- -ran
-,-- (If veteran, give name of War)
..1_
Single, married, widowed,
. -
4 I
Sex --. -_f2._/ -3"4,,, -R., . or clivorced (write the wor Date of Death --`3*2 19 ./Y74_
Age 6 4, , Years Months Days Birthplace
Cause of Death
"\.
Certificate was signed by \ M.D.
Address
Place of Burial (or Remova )
(If body is to be temporarily h.ld,... ..in spa I ter)
Cemetery Date of Burial 19
(If body is to he temporarily ., fill in spa e later
same appearing to be COMP TE
The CERTIFICATE OF DE , H on aining the :hove stated particulars, having been presented to me, after careful examination, the
, CORREC , AN SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
1
tion, have corded it in ocal Record .•ith t e above stated Registered Number, and on je,basi '
ereof I HER BY GRANT A
PkRMIT oLa4A.,
J' / '-C ":
i 6/.., A
to ,./..-?.../itk CL-1/LL--7,../•,.. '""
ame) - (A aress)
the . to hold temporarily and the body
(Und Dated er or pe sonAhap.q. g charge of$.91 (Signed)pse) (Inter, re or o ispod4(state how))
.. . . 19 70 l
II
-1•44 • eAsr..
oral Registrar
This Per it 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.
FOItM VS. 61. (REV. 6/63) (A2-248)
- ....._
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
1 CREMATIONS ARE MADE
7 �
Date lZ r"1 -was %2///1.19 y"‘
(Interment or Cremation)
r
a>i- C
(Name of Cemetery, ErettltrtstRiiim;eTt7)---
Section Lot No. Grave No.
\\)
(Signf(fed) ti2 G t%--
/ <r
(Person in Charge)
Address (, s,11
7 -L-"-(- --e "r- --f:7
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"'* ad
FILE PERMIT WITHIN THREE (3) DAYS with the Regi a
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAI4IS
violating the law relative to the return of permits are liable o
a penalty of NOT LESS THAN FIVE DOLLARS NOR MA
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.
-
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fa' This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. y�
( � ) ii
Town, Village Registered o. V..
Dist. No. "'�� County L/l/ or City
/ (If city, give street address)
Name of deceased ...�.1:.., /.-`°el Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex . , or divorced (write the word) Date of Death y�. '... /1f 19 77 .
Age.. 6 Years.... .M nths Days Birthplace /�.i.411 ,
Cause of Death ----
Certificate was signed by M.D.
Address ma . cztiJ ) e)t-' v ,4
Place of Burial (or Removal) ..
Of body is to b mporarily,he i to s ce late
Cemetery ... �/,t.k-tL!��.,�J2� Date of Burial �� '/S� 19 7c
(If body is to ne temporarily held, fill in s ce 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, have corded i in my Local Record with t e above stated Registered Number, and on the basis t reof I EREBY GRANT A
PERMIT
(Nome) (Address)
the to hold temporarily and ..�,. the body
(Underta er or person having charge of corpse) (Inte , .•ve, • • •e - se dispose of (state how))
Dated ....ry 19 ....7 (Signed) t ,
This Permit is suf icient for the Removal (and Interment or Cremation)of a body to a - .rt o e tate •je+et to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit( S No. 62) is required.
FOItM VS. 61. (Itl V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of -7/1�was 719
(Interment or Ceetnaiann�
(Name of Cemetery, Crematorium, etc.) �JA
Yv�
Section Lot No. Grave No.�‘=
(Signed)
(Person in Charge)
Address 1( _
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 U
TAKER MUST SIGN ABOVE STATEMENT, write acros
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
violating the la*relative to the return of permits are liabl
a penalty of NOT LESS THAN FIVE DOLLARS NOR MO
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.