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Suprenant, Mabel NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT iSF' 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. 4e Town, Village Registered No. Dist. Na .S6G1 County 127:P1h.,!3.�4-^ or City en s/ .S S i4 / ,2 (If city, give street address) Name of deceased ��CL'ft... Veteran i Single, married, id owed, (If veteran, give name of War) Sex `_�2 NfL� or divorced (write the word). . its / Date of Death 6 h.14. 7 19. .' Age 7 Years Mon Days Birthplace Cause of-Death Certificate was signed by °-"4 .. . - M.D. Address _ Place of Burial (or Removal)..., , „ „, -L—' (If body is to be temporarily held,nin spa I t r) Cemetery __ -r/ Date of Burial J.t,1.1L,.1 Q 19 r (If body is to be temporarily held, fill in space ter) The Certificate of Death contain' g the above stated particulars, havingbeen resented to me, after careful exami- nation,,the same appearing to be COMPLETE, CORECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number, an n the basis thereof I, EREBY GRANT A PERMIT tot ?:e : ' .. the `�% ' to hold temporarily and (A drega> the body (underi er or pgrson having charge of corpse) (Int emove,or q e wise dispose of [state howl) Dated 1 19.‘.y (Signed) t• / Local Registrar This Per t is sufficient for the Removal (and Interment or Cremation) of a body 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 / d was ion 19 4 sL (Interment or Cremation , (Nat of Cemetery, Crematorium, etc.) Sect rk�— t No.—{'�- GravgAu./ �_ _ (Signed) — (4,_.- �2,4, c.f .t_ (Person Charge) ed� /� C 6 4 a Address --- -- -- �C Or k--1.2..,i ?), 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.