Saloman, Etta 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. rl 9
- A Town, Vllt - R istere o�l
Dist. No,,? 6L! Cot y or City
(If city,ge street address)
Name of eceased... r.. :-xti—/ Veteran
(If veteran, give name of War)
, Single, married, widowed, / D /
Sexi0 or divorced (write the word) Date of h 19.U..5
Ag r6..Years. nths Days 77Bir place.. _
Cause of-Death ..
Certificate was signed by .. .. .... M.D.
Address .17 - ,-,
Place of Burial (or emoval) — ?z
(If body is to be temp r 'y held, fill in space later) •
Cemetery.. ,C , Date of trial 196_
(If body is to be temporarily held, fill In spec to
The Certificate of Death containin the above tated particulars, having been presented to le, 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 Loc cord with t ahoy
fated Registered
Number and on the basis thereof I HER BY GRANT APERMIT /
to . ..,, .. .... p y
(Name) ddress)
the Ato hold temporarily al the body
ndertaker or per aving charge of corpse)i.-- (1 move,or otb is dispose of Is e ow])
Dated.-� . 19,67.5 (Signed)
Local Registrar
This Perm t is sufficient for the Removal (and Interment or Cremation) of a body to any part of the St (subject to local
cemetery or oth 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 Cremation)
c4-LeL_ ��
(Name of Cemetery, Crem orium, etc.)
Section T,ot No. Grave No.____
a--4-4-4-1-14-04..,..._
(Signed)
(Person in Charge)
L '14)(..)
Address _ .a'
Person in charge must return this Permit to t e 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.