Kitterick, Susan NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(Town Village, or City)his Permit an in e whichthe deathed y the occurredal afttergthear FILINGtand acceptor ance of a CORRECT A of the ND COMPLETEistration District
CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No. 3
Dist. No:,5d( County .._. or City -2-
_ (If city, give street address)
Name of deceased .......... ,*c.,,r Veteran
(If veteran, give name of War)Single, married, widowed,
Se -- or divorced (write the word) (N Date of Death , c - 'a( 19 6
Age Years IVlonth ys ,Birthplace ./)...zra, ,,,,k...1,1 ,....
Cause of-Death
Certificate was signed by
Address M.D.
Place of Burial (or Removal) --s.-
ham
(If body is to be temporarily held, fllkin space later) (,
Cemetery fie... Date of
(If'body is to be temporarily held, fill in space !at x-�` v 1
The Certificate of Death containin the above stated particulars, havingbe
en nation,,the same appearing to be COMPLETE, CORECT, AND SATISFACTORY dAS REQUIRED to me, after careful
LAW,
I have accepted the same for registration, have recorded it in my Local Record, ith the above stated Registered
Numb , don the bs t eof I HEREBY GRANT A PERMIT
to ..,c‘,4e"...„
(Name) (Ad
the 7.1 to hold temporarily and
(Underta er or person ing charge of co e • -- the bodyDated � - 19 (Inter,rem e, or otherwise di pose of [state how])
(Signed) - �..-. ......
This Permit is sufficient for the Removal (and Interment or Cremation) of a bodyto anyal Registrar
cemetery or other regulations), unless removal is by common carrier, in which case Transi Permit theart of Not 6(subject isequired,
Form VS. 61, (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of -�... .I Svas , 19_ Cry
(Interment or Cremation)
'q
S
(Name of a etery, Crematorium, etc.)
Section_ Lot No. Grave No.--
n
i'
(Sign ed) -Z-� `" ..-V7-1-16-,-
(Person In Charge)
Address !r, G��4 .L--, - --- ,-rL -
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 Dis-
trict 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.