Flynn, Ruth 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.
Registered No.
�
Town, Village
Dist. No.�'G/ County �Yt-�-- or City ��
(1 city, give street address)
Name of deceased Veteran
(If veteran, give name of War)
Single, married, widowed, - `
Sex.._ .. or divorced (write the word) l�:n J?1s.-.alj-J Date of De h 4 - /EA 196
Age t Years Monts Days Birthplace- ..... - -
Cause of-Death
Certificate was signed by 46 I� P a. z.1 M.D.
Address ,- ��
A twy �.
Place of Burial (or Removal) ✓ k-u, ..
(If body is to be temporarily held, fill in space lat
Cemetery :..... Date of Burial _a / 19.(5"
(If body is to be temporarily held, fill In space later)
The Certificate of Death containing the a ove 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 registration, have recorded it in my Local Recordwith the above stated Registered
Numbe nd on the basth eof I HEREBY GRANT A PERMIT
tom'
the e)� to hold temporarily and ( .dr the body.
( nderta r person having charge of corpse) (Int r move, or otherwise ose of [state how]
Dated "V.) 19..z ' (Signed)
Local Registrar
This Per) 2.au
is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ct 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 ofIr-y 4,--le-42xr 7 ;was_ )/ o f 19
(Interment or Creme ton)
(Name of metery„Crematorium, etc.)
Section Syr_ Lot No.Aa Grave No.
(Signed)
(Person harge)
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.