Fuss, Lillian 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.
Registered No. ��
Town, Village rs� .
Dist. No, 7.._ Coun 4It�z�� .- or City -
(If city, give street address)
Name of deceased.... .. -",- C Veteran
(If veteran, give name of War)
Single, married, widowed, -✓/
Sex -• Z!x--let- or divorced (write the word)..`-�� c..,2.L, Date of D th //-/y 19...6,5—
Age .6). 6 Years. Months Days Birthplace....
Cause of-Death a2
Certificate was signed by M.D.
Addressg
Place of Burial (or Removal) Y � .. . __.. .....
(If body is to be temporarily held, fill in space Iat
Cemetery C '_..�.. ---' « ate of Burial ,".7-6- 19 t 5
(If body is to be temporarily held, fill in space ater)
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 registration, have recorded it in my Local Record with t above stated Registered
Nu , and on the basis theieof I HEREBY GRANT A PERMIT Gem
to._ ,�
(Name) (Address
the..... .... ... . a to hold temporarily and th body
(Undertaker or person having charge of co se (I , emove, or otherwi di 'se of [state how])
Dated ,ll/ 19b, (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (sub' 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
-1
Date was 19
( torment or
c (Name of Cayttete7,.Crematorium, etc.)
Section Zit Lot No. /D b Grave No• .
(Signed) _ � C.�����
(Person in Char )
Address
Person in charge must return his Permit to Re istvdr
g g
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.