Booth, Voiola 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 p Registered No.
62
Dist. No.-37.0/ County or City
(If city, give street addre•
Name of deceased C-ct::e.ic•- Veteran '790
If veteran, give name of War)
Single, married, widowed,
Sex a-e-- e-e. or divorced (write the word)..__ _ Date of each.... 19 S
Age 9t Years_ (.,,-� Months Days Birthplace --2
Cause of-Death C _
Certificate was signed by "Lk M.D.
Address �`/ . 2.4--x.�. :xtsa at.....�/
Place of Burial Removal)........ U-.-l.tss�
(If body is to bet ora-Iy held, fill yt space later) /J %
Cemetery ._..4. n (/-- 4-e.e ( � , ` - Date of Burial.._. .... X., 19-w�
(If body is to be temporarily held, fill In space later)
The Certificate of Death containing the above stated particulars, having been presen d to me, a ter 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
Numb?" a on the basis there I HEREBY GRANT A PERMIT
to .3j(7_,22-6-,(),4, Paig..day#
d , .� (Name) Addres )
the � E�X to hold temporarily and the body,
Ilidertaker or person having c aege of corpse)
Dated ^ ,, (Inter, o e,or otherwise disp se of [state ho ]
. ' ,� c) 19..��5 (Signed) ���ll e.�4 Local
Registrar
Q
This 'ermit 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, 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
Date of/ w - 19
• Interment re tion)
✓'-��.Pi �y.c_ _ .,QiY.—a-,r�Z--ere. ...
(Name of Cemetery, Crematorium, etc.) 3
Section_ Lot No. Grave No._
(Signed) --.= k"2--', i.., / o (4-
(Person in Charge)
Address (le 3� 7 G- l ..--
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 ii'IVE 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.