Whitcomb, Dan 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 COMPLET CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
G j ` Town, Villag Rel red No. ....
Dist. Ne.� County -e-r' or Cityj _ t �—�.
(I city, give street address)
Name of deceased --'6 G0 Veteran
(If veteran, give name of War)
�j Sin , married, widowed, h /
Sex G.3 or divorced (write the word) �(° : i: BirthP1ace..;
Date of19Age._ Yearsonth. Days �J.. ...... .
/?
Cause of-Death 1L�--E. u. d
Certificate was signed by... h- ,--e E�.n::.,. 9---s �C./ M.D,
Address...��`.Z. i, -- .
Place of Burial or Re val) -1. r i
(If body is to be to y held,All in a later) !
Cemetery t, --C--b� ,.�.2-4- 4 -_.4.: Date of rial I 19.6.h
(If body is to be temporarily held, fill to space later)
The Certificate of Death containing the above stated particulars, having been present to me, ter 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 Record wit the above stated Registered
Number, and on the as' f 'HEREBY GRANT A PERMI to � /�1
( ame, - (Address) I
the��� 1: to bold tempor ily and... , . t e body
( rtaker o person having charge of corpse), -1ra� ter, remove, otherwise dispose of [state how])
Dated t`- --d 19..6..5 (Signed)
al Registrar
This ermit is 'u icient for the Removal (and Interment or Cremation) of a body to y part of the State (subject to local
cemetery or other re ulations), 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 gR
CREMATIONS ARE MADE
Date o wa
(Interment pr rematitf
elseo emetery, reinetorium, etc.)
Sections Tot NoS., Grave No:
(Signed)
(Per,n in Charge)
t
Address /C O /
1- 1/1
- 1
Person in charge must return this Permit to the Registrar
of his District within SEVEN 47) 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 Registirars are required, under penalty,
to report violations thereof.
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