Seaver, Timothy 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.
inIgieW Registered No.
Dist. No. 1401 County ERA or City BU FAID—CH,IiERNS..HOS.PITAL
(If city, give street address)
Name of deceased TIk ?TRI...DAR t..SEA.VER Veteran .NO
(If veteran, give name of War)
Single, married, widowed,
Sex MALE or divorced (write the word) SINGLE Date of Death AUGUST 24 19 .7......
Age 1 Q Years Months Days Birthplace NEW YORK STATE
Cause of Death RENIa...FAILURE
Certificate was signed by HIKAM MATSUDA M.D
Address 21..9..BRUNT...5..,...BUITAW.AE YORIC
Place of Burial (or Removal) QI E Di pun
(If body is to be temporarily held, fill in spac.. :.,I, VIEW CEMETERY AUGUST 27, 76
Cemetery Date of Burial19
(If body is to he temporarily held, fill in 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, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
to REGAN..4..DENNY INC.. QUABER...Rt)AD..DIENS 4 ,.NE YORK
(Name) (Address
the FUNERAL DIRECTORS to hold temporarilnd INTER 'the body
(Undertaker or charge o rpse) �:4(I er, rem e, o `otherwise dis ose of (state how))
Dated A`� �� 'av f 19 1 Y '�
(Signed) .. i.v�... `-'1----
V.M�.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any/part of the State (s bject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit ant
S No. 62) is requir d.
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 o was 4 7 19 ,74e
(Interment or Cremation)(/
E?.64.-Ci21
Y a
(Name of Cemetr rema
Section No./ � Grave
(Signed)
(Person in Charge)
Address IX > } "e" ''
Person in charge must'retum 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.