Harrington, Sanford 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, LE IBLY WRIT'T`EN IN DURABLE BLACK INK. 1
/ � Town, Vi egistered No
Dist. No5— County. C o3—Eity-
(If city, give street a r
Name of deceased .).1-.I±.R.l? ti A.eR RI t ( C- G Al . .... Veteran ..__ 1
.(.1P eteran, give name of War)
Single, married, widowed, C
Sex .. .._.4 or divorced (write the word)._._ . Date . .
Age ..C) rs..,........ 1Vlon ..__ D ys ? Bi place... ._. ..
Cause o 'Deaths ''. .... .... �? ,►-r
rL t
Certificate was signed.by .... . <. r r _A.. M.D.
Address .C.:‹. r......
Place of Burial (or Re ) s ,
(If body is to b$ tet,nporar' h I m sp • '1i'r)
Cemetery �/_ ._-.. i.`_ 2.. - ,_ Bate of Burial ..._ (/./?�1
(If body is to be temporarily held, fill in pace later) / 19`�.lj
The Certificate of Death containing the above stated particulars, having been presented t me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATI FACTORY AS REQUIRED BY LAW,
I have accepted .e same for registration, have recorded it in my Loca co with the ab ves ed Registered
Numb -ad on M' , .ate" reof I HEREBY GRANT A PERMIT
to �`a0isi �—' AO..3..4'6 _
far (Name)
Il Thddress)
the -:,..._ to hold temporarily ._. -‘,__ e body
( e aker or person having charge of c se)/ (Inter, removother s di ose of [state how
Dated 19C2 (Signed)
( ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a ody 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, 82) is required.
Form VS. 61. (Rev. 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS CAR
CREMATIONS ARE MADE
r
Date (___—_w s I Y_19_ --
(Interment o re ion)
(Name of Cemetery, Crematorium, etc.)
Section """" Lot No. '" Grave No.
6,(Signed) _ �'G ti t
(Person in Charge)
Address L
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.