Flint, Agnes NEW YORK STATE A-1 E DEPAK l MEIN-1 Or riLAL in
OFFICIAL BURIAL (OR REMOVAL) PERMIT
OS ' 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 Q� Registered No. 3 4I4
Dist. No. 6 d County .f. a?l'�� or City !,1, �
(If city, give street address)
Name of deceased 4,, T Veteran
°
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word)._..,1 �2 i i Date of D t .... . )- 19 Y
Age '/ rs..�/ � onths _ Birthplace...., ,.yl :......
Cause of-Death. � CJ.. ; Zly6s,..64:1
Certificate was signed by .S.t�e.y!l� 1?L M.D.
Address /
Place of Burial or Removal).......� . 2.
(If body is to be rp arily held,.fillin space later) � -
Cemetery -.4-ZeE..2/Z(4&f'' Date of Burial -1.-. ...2e-5- 19.6V
(If body is to he 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 he 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
Numbe , nd on the l��sis erreooEREBY GRANT A PERMIT
/ r (Naaf (Address
the (�to
/ to hold tempo it and.. . the body
rp(Undert r or p rson having charge of cose) er,remove rwise dispose of [state howl)
Dated 19_..`} (Signed) ,
• Local Registrar
This P mit 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 19_
(Interment or em ion)
s
(Name of Cemetery, Crematorium, etc.)
Section Cr7c.fr Lot No. Grave No
A
(Signed) _7:•••'-7./ Le
(Person in Charge)
Address
17)
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 DIRECTOtRS 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.