Petrie, Baby Girl NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tSi' 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. Registered No.
Town, Village
Dist. No � / County �itJ .• or City •:•� /�
(If city, give street addresb7l
Name of deceased Zt J {= '" Veteran 1-o «1�///
(If veteran, give name of War)
pp��.. Single, married, widowed,
Sex...lh:�m'o..R.R.--• , . or divorced (write the word) --e -- Date of Death /a v?.G. 19�,e
Age Years Mont s............./. ...Days _B.rthplaceJd�... .. a�...�...r
Cause of-Death L` 6. _ h2.
Certificate was signed by — 3. � � � M.D.
Address .... ,.._, .
Place of Burial or Removal ...,... ... .,. -�-‘)
(If body is to b-apPrarily held, I space la or)
Cemetery • Date of Burial...4 ,. .2 19 4
of body is to he temporarily held, fill n space later)
The Certificate of Death containing the above stated particulars, having been presente to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORREU1, 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
Nu ar and on theis t ereof I HEREBY GRANT A PERMIT
to ,j' / ../ze4,21 -l1 ,) '- ..t ,,.. .
Name) (Address)
the to hold temporarily and the body
(Underta r o� per on having charge of corpse) Inter, remove, otherwise dispose of [state howl)
Dated /)-� 19 (Signed) iitick
Ik
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of he 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
,___,f i I `� ,ell
Date o f ��s-- w c. �.' 19 /
(Interment or remotion)
C— , �—
(Name of Cemetery, Crematorium, etc.) j
Section_—__ T.ot No. Grave No.%I 'A
(Signed) .. _ "17c_--_4_ ..� v '
(Person in Charge)
i
Address Cy' 1 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.