Van Ness, Leo NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
6' 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No.
Dist. NoK Z Count 4 br-Ezty 2'11-447-4` "'
(If city, give street address)
Name of deceased.. -..-e-� Veteran . `�)
(If veteran, give name of War)
Single, married, widowed,
Sex C- or divorced (write the word , Date of Death,,6'e c- / )" 19 ,. X
Age 7 d Years____ Months �i Days � Bir place
Cause of-Death ��
Certificate was signed by.... .. - (- �-O ..._. ... ,9 M.D.
Address .'. , ..fix.,.- _ . ' Y 1
Place of Burial (or enioval),- 2 lr
(If body is to be temporarily h It fill in space later) v
Cemetery._. .Date of Burial. ..2,c, .e..1.5 19...
Zry
(If body is to t�orarily held, fill In space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record ith the above stated Registered
Numb , and on the basis Sher f I HEREBY GRANT A PERMIT f� �i�_g�
to .4-'' �.c"'. 3'c-fT.c-:_ j�32 it
(Name) (Address)
th • to hold temporari1y-,nd the body
( tataker or pets having charge of cfas b Inter,rem v ise di e-ef—(state how])
Dated. ,/ PC. r � (Signed - -
(aK ... Local Registrar
This Permit is sufficient for the Removal (and Interment or Crematio of a bty 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.
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' �„%i2,14,1—u�was t' cam.-- 19
(Interment or Cremation)
�% .- ---� -- -jam'.
'I
(Name of Cemetery, Crematorium, etc.)
t
Section Lot No. Grave No.__�
(Signed) _ �/G0-�� a� ----- = ` _ �e-72i�
g (Person in Charge)
Address et ". _—__ = f—
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.