Bird, George 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 COMPLETE CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Regi ered No.
0--ri----:P---arx---e Town, Vill -r�
Dist. Na J�', Coyxlty or City r; r �'
�' (If city, ' e street address)
Name of deceased c' z.....: ��� �:. .. Veteran
(If veteran, give name of War)
Vic, maned, widowed,
Sex-- -• -• ..., or divereed (write the word}�� t't--- ate of th 1l �..: —. 19
Y6 rs. — the _
g �vI t3 �-- ....Days f Birthplacera �r � ......�..`.-�
Cause of-Death ` t'_2-`4 -::E. . :1::e —* -t ,
Certificate was s' b ZlL$'-�� $... M.D.
Address �. -- ... � '
Place of Bur' (Qr Removal)...,p ,. V. Qt f-'71
�-r.i "6
(If body is to JJ ;� porarily gid, rat ace later)
Cemetery./i l��e -t _ ,Date of Burial I. ���JJJ 19 L
(If body is to he temporarily held, fill in space later)
The Certificate of Death containing the above stated pa eulars, having been presented to me, after careful exami-
nation,,the same appearing to be COMPLETE, COR ECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the sa for registration, have recorded it in my Local Record with the above stated egistered
Nu ,e , and n the basist °f I H REBY NT A PERMIT/
•
-
�„e) , ddr ...a ..
the.. Q` : .� ..1 '�� o hold tempor ' nd . ._. .. . ..the body
(U ae aker or persoAav, charge of co}}r�se (In r, moove,Tar ethetwis is state
Dated 190- (Signed)... ���'= :,�--e--�—e / -
Local 'egistrar
This Permit is sufficie for the Removal (and Interment or Cremation) of a body to •- part of the State (subj-ct to local
cemetery or other regulations), unless removal is by common carrier, in which case a Tra sit 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
per._
Date of was '2--' 42-4 19 6 /
(Interment or re atiOn)
PFama of,Cemetery.;,Crematorium, etc.)-
If
Section' �L• Lot No. Q� Grave No.
(Signed)
(Persom in Charge):
Address:
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.