Read, Martha NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
pSF' 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 >r� Registered No.
Dist. No. ���. County �a�,-'� or City aQ
(If city, give street address)
Name of deceased 7,4 e ..: .. .,,s�...__ Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex--- or divorced (write the word) 7.%.6(!?!3s, -/ Date of D .i.-fi 1,.?^4-.5
Age k Years Months... Days Birthplace -2)--. V i.
Cause of'Death -' J
Certificate was signed by - M.D.
Address ...-
Place of Burial (or Removal)........
(If body is to be temporarily held, fill in space later) ( ( � r
Cemetery ?�.=4 ./ v 11- Date of Burial - 19..ti
(if body is to be temporarily held, fill in space later)
The Certificate 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 regis ation, have recorded it in my Local Record with the above stated Registered
Number an on the basis th eof HEREBY GRANT A PERMIT
��� (A re s)
' theN a to hold temporarily and / the body
(Und aker r person having charge of corpse) (Inter,re , r gtherwise disp o [state how])
Dated /:/-5-- 19..E (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment )r Cremation) of a body to any part of the State (subj to local.
cemetery or other regulations), unless removal is by common 4arrier, in which case a Transit Permit (VS No, 82) 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
Datesei
2z• wa 19_6 J
(In erment o. )
(----2/7
(� JJ
(Name of CsppAtery,.Crematorium, etc.)
Section of No./7,4 Grave No
��//� 7 '.
(Signed) �� 2
(Person in Charge)
i--
Address L`"( ° .;= �)\- '
,,,,..„41LA
Person in charge must return this Permit to the e
rar
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 Registrars are required, under penalty,
to report violations thereof.