Clark, Anne 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
Registered No..c-7
Dist. Na_."1 C.'L. County._ a•-)-r e- or City At "
(If city, give street address)
Name of deceased '� 4 - Veteran
(If veteran, give name of War)
Single, married, widowed, 7,, )� -"-
Sex fj14^- ( -'" or divorced (write the word)...4( �Y r Date of D, th `�( 2' 1 4-s
Age ,.5../__-.Years_ Months Days yirthplace 7.:- ?s:...
Cause of-Death L ec�i �y� ... 1� k�� �.. .
Certificate was signed by 1-� . ? , . - -�-_--t-+ M.D.
Address . -,.e- Y' . '...
Place of Burial Removal) , -4.7�kz / --,4-,-z-��,- ''u-- � 7
(If body is to be t ponly held, ll,in space later)
Cemetery (•-.'-�' C_rZ ., ate of Burial -�� 19c- i
(If body is to be temporarily held, fill to 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 registration, have recorded it in my Local Record with the above stated Registered
Number;'- d on the basis eof I H REBY GRANT A PERMIT c.
to .GC..-.. .�4_.: .a,�_ ._- ti.2i- .-r:Ca ' � � 6._.
( (Address)
the Lf :r to hold temporarily and t e body
(Undertaker or person having charge of corpse) (Int , e ove,or otkerwi 's eof [state ho )
Dated --).a..-:.‘- '......., :._ 19..‘.S. (Signed)
Local Registrar
This Permit is su icient for the Removal (and Interment or Cremation) of a body to any part of the State (s 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. 6I. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of -.. ( was,4' / `' 19 5-14
(Interment or '.+nano¢)
___t=4„.._ ‘„ - ' 'Zs—-, .-
(Name of Cemetery,.Crematorium, etc.) (
Section ,, / T,ot No. /0 8 Grave No.___
,/�
(Signed) — rJ. _� -I,,/ "?l 4/
(Person in Charge)
a _4,,,., „ir,..
Address ir*----
4-. <-k "'- r
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 DIRECTOtS 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.