Underwood, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
OSSF' 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
. To-wm-VilittgA... .,,o, 7
Dist. No. ..,...ir.1..e..i. County. ( or City
.)7 (If city, dstreet address)
71Z-)
Name of deceased .... %-4.-- t-1 U--7-1....e&-.4-- Veteran
(If veteran, give name of War)
,
Sex /1.1_,Z14-22---- Single, married, widowed, Date of or divorced (write the word ---er(--e--' Death
Age // Years. Months Dayy
CauseCertificate was signed by , Birthplace
of-Death G..4 ,-..e.i..-24.---g-1_,,4.21.---"f i..."--"--4:7-A-L.4
, -- -----c- _.,a t-e M.D.
Address ..-2...-.(>4. c. _.
Place of Burial (or emoval)
....,e_.:___,. ,,,,,___49 L-' --t-12 . .
- X
(If body is to be temporar' held, fill space low)
Cemetery '--....-r:f...-.-::).-,...4' Date of Burial 6 - 19.Are
(If body is to be temporarily held, 1111 in space later)
The Certifilate of Death 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 accepted the same for registration, have recorded it in my Local) ecord with the above stated Registered
)Numb r, and on t. - baiter HEREBY GRANT A PERMIT ./
y
).„,
r .
. (
ss)
the U.-2 .,' l to hold temporarily and the body
(Undertaker or Ten having charge of corpse)_-- (Innz.move,or otherwi 'spose of [stat w])
Dated 0 — 19 (.67 f., (Signed) 0 .,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Stat (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
c
7
Date of was 19
(Interment or 'ear)
/
ame of Cemetery, Crematorium, et •
Sectio 9 _Lot No. /7S Grave No. r
r
n
(Signed) iZ
(Person in Charge)
c.
Address 7 � %�'�
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. Jf 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.