Stoll, Elsie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL'BURIAL (OR REMOVAL) PERMIT
(a' 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./ ��
�,;�C��2�yL� Town, Village Regio. ..
Dist. No.( Q, County Ll/ or City `�� � Y.' T
(If city, give street addr s)
?.. 4 J'--A,..te___Name of deceased . ... Veteran
ef
ran, give name of War)
2.4Single, married, widowed,
Se or divorced (write the word) Date of Deat /(r- 19 7‘.
Age .6,,,� Years :: Months ay Birthplace
Cause of Death O ,
Certificate was signed b M.D.
Address 0 X5.;1 y
Place of Bur' (or Removal) .. �c n.zr
(If body is to temporal� held, i n space l
Cemetery .....:!(oi _....C/�l cl1 Date of Burial ... � 7 19 �C.
(If body is be temporarily held, fi n space later
The CERTIFICATE OF DEATH containing the a ove stated particulars, having been presented to me, afteriVareful examination,the
same appeari to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have orded it in my cal Record with the above stated Registered tuber, an on the basis erreeof I HEREBY GRANT A
PERMIT ,6�f �Cr f �%i/ � Lam` '�.o -('4
t0 Na � (Address)
`,%
the to hold temporarily and the body
Dated(Underta or rsoyring charge19f rse) (Int�r, remove, or otherwise dispose of (state how))
(Signed) �.j //''yy4
This Permit is fficient for the Removal (and Interment or Cremation)of a body to apart f th��t 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. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of<y7 d was / 7 19 /
(Interment o
iL-
(Name• of Cemetery, CsPR+arnrium, ever)--
Sectio `6v_Lot No. /'` UGrave No.
(Signe
(Person in Charge)
Address z;4—
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.