Benway, Richard NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ISF 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.
/ Regi ered No..... g
� cr Town, Village ,
Dist. No 7-2�1/... County..-. .rig _ or City L-- =� city,. .. ....
it (If give street ate ressr
Name,&f deceased.. .. . ( _ stole"
Veteran
(If veteran, give name of War)
Single, married, widowed, a
Sex -1 or divorced (write the word).- ... ..__Date of D — 19-�
Age- .. ._.,J Years. Months Day Birthplace_ .,R: y A .. ._..
Cause of'Death. .��,hc __.,,,�� _ ._ - �.yL4 -
Certificate was signs by.. . . c� .r M.D.
.LP�, r-c., M.D,
Address_ -. y� =.- Gal._., f-Z---.: -
Place of Burial (or Removal) - ..__ -4... ..9
(If body is to porarily held, fill•' p a Tatar)
Cemeter . ` _.- -- -Ktfr, .4..., .Date ial �.
(If body is to he tomporari y d, space later) + / ... 19_.SP..(�
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 SATISFACI ORY AS REQUIRED BY LAW,
I h ve accepted the same for registration, have recorded it in my Local Record with the above stated Registe ed
N m er, and on thA ba i3 er of EBY GRANT A PER IT
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to. -`' _
r
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�'t'� !'G �� (Add ss)
t e to hold temporarily and .. e b
(Undertaker or person having charge of corps ) . — (Int , e, or otherwise a of [state ho
Dated-..- r ',G 19. a-.lS (Signed) s
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (su ct to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) 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
Date fz;"2"/� - wars/per /7 19—"�
(Interment or Cremation)
`Z//7
et gg'emato11- t - G
(Name of emetery, Crematorium, etc.) J
Section Lot No. / .Grave No _
(Signed) ; •
erson in Charge)---
Address 6'7 ! Y/L
Person in charge must return this Permit to t e R tray
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.