Busher, William 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-C7ER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. N ..�SLLtd Town, Village
Dist. No.t� k U 1 County a ti or City }2df2t_t,t__1:.e,ered
`Q
/ (If city, give street 1 ress)
Name of deceased (< - �`4-'' Veteran �/AY/ lK�!/
-
(If veteran, give name of War)
6)1L0 Single, married, widowed, -
Sex or divorced (write the word) Date of th L 19
Age 7 ....Years Months .Day - Birthplace } /Irl 7
Cause of-Death.... . ....
Certificate was signe by ..... :-.- M.D,
Address �, . I 1
Place of Burial (or Removal).... ,tfd. _Q a /
(If body is to bet my held, fill - space I )
Cemetery WI, • Date of Burial 1 7 19 t a
(If body is to be temporarily held, fill in 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
Numb r, and on the b is thereof I EREBY GRANT A PERMIT
, ( irr ss)
the v to hold temporaril and the body
(U ertaker or persop)aving charge of corpse (Inter, rem ve,or otherwi dis ose f [state how])
Dated ,/ 19Z-'Cr (Signed) j t....... �
ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Sta a (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
Date off' Lc ----�'% " was �'G'LA:. J 19 6
(Interment or C motion)
/r
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signe .%" e•e '
(Person in Charge)
,•,,t f ,�'f a
Address
_ 1. Z6 :sy
Person in charge must return t is s Permit to the Regist
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.