Hungerford, Nora 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.
l Town, Village Registered No. c3
Dist. No, r�1.... County '�/ ---e or City Ms
(If city, give street address)
Name of deceased ----?DVL-Q- ,! Veteran
(If veteran, give name of War)
Single, married, widowe ,
Sex —0-40-.0--6- or divorced (write the word)....‘ Date of Death..„.. 2'4 19..‘.5—
Age b Years Months.. Days 3Birthplace
Cause of-Death
Certificate was signed by ,..ems.. .. M.D.
Address .--,
Place of Burial (or Removal) et-w-x� V
(If body is to be temporarily held, fill in space I er) - n /
Cemetery ., - ` �it —' D e of Burial ?7 19..C4`
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presente 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 wit the above stated Registered
Numb r and on the b is th I REBY GRANT A PERMIT ��
�I,
to0. ! /�✓ •..
(Name) (Addr )
the '� to hold temporarily and the body
(Un rt ker or person having charge of corps.)_--- (Inter, a ove, or °them. pose of [state ))
Dated 7-7 19 S (Signed)
Local Registrar
This P mit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (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
_r
Date _,,. ....i._._____
was 19
(Interment or Cremation)
i7,,,,, 2 r ,f__,'/'' (7. ------- .-
-,,, , r
(Name of Comet ry,Crematorium, etc.)
.eLdree r- --dX3 Y-7 7 it-1.4 c p‘
Section T,ot No— ---. Grave No.___ ---
,
(Signed) 17� �
(Person in Charge)
Address )f // //77
Oj % .— :
d
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
win be enforced. Local Registrars are required, under penalty,
to report violations thereof.
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