Morris, Vernon NEW YOKK S1A-1t L)LPAK1MI✓N1 or titAL1n
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No.
Dist. Na .5.. ®.-I. County 41.4..t.u.....,..< or City .- -
�__ _ f city, give street address)
Name of deceased C�-- I". 722.44.21-kAK7 Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex ..KtIR .�.., or divorced (write the word)..--.RY.?h-S ...Date of Death � .c?l 19
Age fi. i Years N10 hs ays Birthpl e
Cause of-Death
Certificate was signed by :...t fir.. ..._. M.D.
Address
Place of Burial (or Removal)..., ,,,,Q�-.a.!.ed: . r
(If body is to be temporarily held;fill in space later)v
Cemetery ' - r,,..� t_ Date of ial 9 o 1 19 e-
(if body is to be temporarily held, fill to 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 ,,or registration, have recorded it in my Local Record ith the above stated Registered
Number,, and on the basis tthereof I HEREBY GRANT A PERMIT /
t✓1�¢-j
the am
temporarily e) ;J to hold and. dress
p g g ,(Inter,re o wise dispose of s to how)) the body
( dertake or person Navin charge of co rp t � s��/
Dated.. ?'--k- 19 b- (Signed)
Local Registrar
This Permit 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 was ' Z 19
(interment or Cremation)
(Name of Cemetery, Crematorium,-etc.)
Section -2 &t Trot No./2-- 0 Grave No. 2--
(Signed)
(Person in Charge)
L�c- j ,
Address lL�'
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.