Harrman, Lena 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 COMPLE2'E CER-
TIFICATE OF DEATH, LE BLY WRITTEN IN DURABLE BLACK INK. / �)
5. r C ,�CI � Town, Villa egistered No
Dist. No, 1 ty W To wity
(If city, gives eet a ress)
Name of deceased /"�• ...� `." • Veteran .. •
F veteran, give name of War)
Single, married, widowed, -Sex . or divorced (write the word).-. ... .- ..-Date of Death k//'
►.. 19 CS/
Age E79.-. ears onths ays place
Cause of-Deat .. . . ... ..... ... ..
1
t - - Zs's1
Certificate was.sig�lec�by... .. .. .,.. , .D,
Address �. •
Place of By :l (or Remo , 1). . .... .,. .
(If body is to b-V a; r' in ace later) 0 "
Cemetery- ob. •,„. Date of Burial t- " h 19C.-�
(If body is to be temporarily held, 11 space later)
The Certificate of Death c ntaining the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW
I have accepted the same for regist tion, have recorded it in my Local ecord
ecord with th above sta`ted�Reg'stered
u Tv : :d on the is thereof I EREBY GRANT A PERM6T 5l_ . • +'�''"''L"�
ame) Address)
theme., to hold tempo ril and -- .. the body
y.
( ndertaker or p on having charge of c pse)......,--
Dated (Inter, re o e, o er is dispose of [state ho )
1 2--. 1 e) (Signed) :C---- --------- ----
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, 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 of2!x4zzi was /&--e- / _19_"3
(Interment or Cremation)
(Na e of Cemetery, Crematorium, etc.) _
Section_ 41 T,ot No. c 3 Grave No.
(Signed)
(Person i barge)
Address g � - / ��-�•
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 .:crds "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 OFFENSF,, The law
will be enforced. Local Registrars are required, under"penalty,
to report violations thereof.