Barney, Christina - NEW YORK STATE DEPARTMENT OF HEAL!ti
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 COMPLE_CER-
TIFICATE OF DEATH, LEGI$�,Y WRITTEN IN DURABLE BLACK INK. QQQQ
Town, �+;•i�ing�, Registered No
Dist. Na ay... County g . y
Of city, give stye dress)
Xame of deceased..C.ti_V..1...5.1...J /VI (BA czn r Veteran
(If eteran,'give name of War)
Single, married, widowed, , ,� �/'
-
Sex or divorced (write the word) `'� Date of Death 19. �]
Age / Yet ont Days • thpla
Cause o Deat L.�s > '
Certificate was si ed by �__ _ ______ __ __ :_._._
Address : - - . .......... .. .
Place of B :l (o 'e la
(lf body is to b- t n••.. �� '1f space 1 t r)
Cemetery..__ . ,1 o -u.. L ., Date of Burial 6a - �.q? 191e�s
(if body is to be temporarily h AII in space later)
The Certificate of De. = containing 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 acce ted the same for registration, have recorded it in my Lo Record with t e ahoy stated Registered
N her, an o th s' ereof I EREBL GRANT CA PERMI
to ^rti.
Name ess)
the . to hold temporaril a t body
..
( ndertaker or erson having charge of c se) (Inter,remove, rwi e ' pose of [state how])
Dated.. ,— 1 (Signed) - ..._.
Local Registrar
This Permit is sufficient for the Removal (and Interment or C mation) of a bo to any part of the State (subject to local
cemetery or other regulations), unless re al 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 G was _2_-19 ti
(Interment or Cremation)
(Name of Ce On,Ceemeterium,mte.) _
Section Lot No ' // Grave
(Signed)
(Person in Charge)
Address _ ° r
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 (a) 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.