Silvernell, David 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.
�/ Town, Village 7�gistered No.
Dist. No. 0 County p�/� �d72 TiILr or City
,/a -4 iiix�6f��� _,� (If city, give street address)
Name of deceased v/1//l/JG�. KJ[/ �e�%f//// Veteran. -7-C-4
(If teran, give name of War)
Single, married, widowed, )��
Sex ! .. or divorced (write the word)---.,1 Y-1 Date of Deat .... - --L....,1,91 ,S
Age 79. Y ;rs.,�, Months.....- Dnys i-rthplace-._.,/�!.... tl tr.7.-.il 6- -
Cause of-Death `% L �:-'. . ��z4tic l -
Certificate was signed 7 - � , r M.D.
Address „...._ .: :c./.. r�
Place of Burial (or : _ 1 oval)..., i"/ ,. tx,�.� .. .�& �-c"7-
(If body is to be tempor: eld, fill in sp e-later)
Cemetery -<- 1. _G-si'' 47 Date of Burial -14-.-2 - 19 G
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented o me, after careful exami-
nation,•the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ed the same for registration, have recorded it in my Local Record with the above stated Registered
Number,2ffl the basis th Feof I HEP B_Y GRANT A PERMIT //
to u 7 "-� G.<e '• .
(Address)
the to hold temporarily and ts.. . _.. the body
(Undertak or person having charge of corpse) (Inter, r v , or otherwise 1 se of [state how
Dated .� 19.E .� (Signed) C._.,,1
Local Registrar
This Per ' it is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su ject 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—
Date of was 19 �
(interment or C anon)
r — ..
(Name of Cemetery,. rematorium, etc,)
Sectio 4ot No> Grave
Si nedz_ `�j �
(Person in Charge)
AddressPerson in charge s return his Pe it to�ttegistr�
of his District within SEVEN (7) DAYS from above date. If no fJ
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.