Thorpe, Baby Boy 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. /‘6
) Town, Village Registered No.
Dist. No. 6 0 / County (- — • or City _,c 41)
(If city, give street address)
Name of deceased " ,c� Veteran (If veteran, give name of War)
Single, married, widowed, ,• p�
Sex or divorced (write the word). - -- Date of D th... •3D,t 19.‘s
Age Years.... Month Days Birthplace / � .,..7,.:.
.
Cause of-Death .........
Certificate was signed by _Q.-.. M.D.
Address ! , —.-. i+- '
04
Place of Burial • Removal) _ _ �,�-,- GJ. ..
(If body,is to be to iir ly held, fill in space later)
Cemetery -. : .� e{i.) Date of BwriaL.. .. /1 19..
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated rticulars, having been presen d 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 Record with the above stated Registered
Numb , nd on the ba4i ., ther I HEREBY GRANT A PERMI/T
2
the dL4-
.< to hold temporarily and the body UUU
(Undertaker or person having charge of corpse) (Inter,rem ve, or otherwise�d_ip se of [state h w )
Dated.. R :G� 3j 19 6'- (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( bject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS Na, 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
dh
Date ot. was 19 l2 S
(Interment or Cremation
(42
(Name of Cemetery, Crematorium, etc.)
Section_ — Lot No. Grave No. X
kY C-121 ` T
(Person in Charge)
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 Registrar,; are required, under penalty,
to report violations thereof.