Buckbee, Lillian NEW YORK STATE DEPARTMENT OF HEALTH
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 COMPLET yCER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
.'// { Town Registered No.
Dist. Na� County bS . CV oc Cry
(If city, give street dress)
Name of4
deceased..... ...1.E,....-.i. ti v � .7 c J(-. E Veteran
Is.::::
veteran, give name of War)
Single, married, widowed, (`/c
Sex . 'r t„ or divorced (write the word)... ........!... Date of th 1 19
Age rs.,. _ 1 hs ays , Birthpla
Cause o `Death. .. . ... ... . ... .... • _
.. .. ... . . ..
Certificate was signe4,by .••-4... ; M.D.
Address---- 4. ..-e:
Place of B tal Remo al)..,k
(If body is to to arily held, Il n sotto, la )
Cemetery _,,. ..,< \., .. Date of Burial S `-- I 3 1 (�/�/'
(If body is to be mporarily held, fill In space later)
The Certificate of Death containing the above stated par iculars, having been presented to me, after careful exami-
nation,,tife same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have •pt:, the same for registration, have recorded it in my Loc !ecord with the eve stated Registered
Nut• utt:nd ., the a s eof I HER Y GRANT A PERMIT
9 .in 'Nagel 'Il i --rf�ld,es.)
the . % ' to hold temporarily o the
(U er or person having charge of rpse) (Inter,remove,or iat - dis a of state how]) y
Dated .:. I.. 1 (Signed) y --
T....
•
` Locals Registrar
•
This Permit is sufficient for the Remov 1 (and Interment or Cre ation) of a bodit a any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier. in which case a Tr.asit Permit (VS No, 82) is required.
Form VS. 61. (Rev. 6/63) (342-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of _ a 19
(Interment Cremati
}‘?
(Name of Cemetery, Crematorium, etc.)
Section Lot No. 4'0 / Grave No._r.
(Signed) _. __ pie
(Persoh in Charge)
Address. - >iLd '('
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.