Frasier, Nelson Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr This Permit can Ira 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK 1NK. -Town Registered No—../..7....._.,,-,,,.....
,-60/
Dist. No..4.i County.... ........ or Citye,--- yo.--,/<2.........
Name of deceased 1-, 2(--Y"--01--vd--e—e----) &/.. e. Veteran
Single,/4-40-4---
married, w owed, .... (If '.ty. give street address)
(If veteran, give name of War)
Sex".,f7id..Color te....) or divorced (wnte the word) , 110--0--,`---L-ezigbate of Death -3 - 3 19 77
Age / Years _ Months r".r.. I3irthplac --,---.44.4v..". ljltr'N'•'
..,-‘,--fr....4....-
..-..4.---, M.D.
Certificate was signed b;-.1711.7 . .
Address i .--. .a-'9-----A
,..._.) .
Place of Burial (or Removal)..:.-Z--7.-2N-........ c-(---r.-^—e-e-r---9
(If body is to 12?)zorarily nplll,till in spice later
,
..Cemetery. - --e-- )--'--' J 7.-/ A-"---,..) ..4.,-.-m.--.-r....- Date of Burial - . 19 6,7
(If body is to be temporarily 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 with the above stated.Registered
Nu, , and on th,....._le b is ____te I REBY GRANT A PERMIT
to.
...r.r_A.,.....)ti:so ,...... ...„ (Add rao
the to hold temporarily and. the body.
(T7takar.p?rson having cling,of*pm) (Inter,r ye,or oth mime disnose of[state how])
Dated 19.(407 (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 care a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date � �19
(In te men t or Cresat an)
/i7L •
lI (Nese of Genie ry, Crematorium, etc.) /
J
Section � -a Lot No. 1 3- / Grave No.
(Signed) / .�G ✓ " Ci'''l,J
(person in charge)
Address ti
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the wDrds
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District 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 re-
quired, under penalty, to report violations thereof.