Linehan, John NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
«' 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.
}2.Town, Village Registers No. .... .. ..
Dist. No. /�65 // �/�County V" or City
(IE city, give street addres��
Name of deceased -)' , �� Veteran(.9 C/CC
veteran, give name of War)
Single, married, widowed,
Sex .... ' ' or divorced(write the word) ....( r-F--c(....Date of Death .. 1997
Age L .re, Years'... Months Days Birthplace
r—A-40:7/
Cause of Death •
Certificate was signed by tV - M.D.
Address
Place of Burial (or Removal
.. . ..... ...
(If body is to be porarily h 1 , {ill to spac ater5
Cemetery Date of Burial 19 76
(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, ter 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 it in my L' 1 Record with th above stated Registered Number, an n he asis thereof IHE��REBY GRANT A
PERMIT � C�,C a-1L1.-Y `�jf�.Ge /a--FU/
to • Address)
(N fix, /�the to hold temporarily and ,.. the body
(Undert er or pe son '...
having charge of car se) (Int e ve, a oche dy,Spose of (state how))
Dated ¢f 19 .. .6 (Signed) ear- (f��i�
... .
Local Registrar
This mit 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. 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`>y2 "���rn4'' was • 19 7
(Interment o
(Name of Cemetery, Cre eie—'--
Section Lot No. Grave No.
(Person in Charge)
Address
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," *id,
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 Milk
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.