Eddy, Dora 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, Verge
Registered No. 27
Dist. No... `�__ Count . .l c .r or-City
// (If city, give street ad ss)
Name of deceased ,!'�`'4 —^ � Veteran `—n—,e?
(If veteran, give name of War)
' Single,'-married, widowe , ,q
Se- • or divorced (write the word) (2. Date of Death _ / — 19..
Age____. Year . Mo ths. ,�a pla e
's Birth
Cuse of-Death.... I__ .. _ ,. n �. - �� L �.�
Certificate was signed >r Y 2ifo....L..�,_ M.D,
Address.--- _ -.. ... �,... .. ...... ..
Place of Burial (or Removal ...,hL 's -...G-
(If body is to be t�mpararily haled, flu t s co later)
Cemetery -f.-.., f- .-.- I. C to of Burial 3 19-
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, h ng 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 Rec rd with the bove stated, Registered
Numr,ff o the basis hereof I HEREBY GRANT A PERMIT :'^ � , � �
' ‘ .27.. ...
to
( (Ad'dress
the . .c .. .... to hold temporaril and the dv
(Unydertaker or person having charge of co s ) (Inter, re statemove, o env' a dispose of [Vow
Dated v� -- / 19. a (Signed) :4-€
L Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod to any part of the State (subj ct 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
c
Date of _was .,---.....,,,,,3 19 '
Jja.„/-
---- (Interment or-G?emndu�S�
/ n +�y� fyJ/ � �A GL2,I `
t.• ...
l� C
(Name of Ce�er�;-Gtematormm, etc.)
-� Lot No.-' - Grave No.—_- ~--
Section_ —-
(Signed) / l71 is -( �� `� Z 2 (C:
erson in Charge)
Address 6 c- )-7.,,,,.+-`e L ""-J'''" ^-
Person in charge must return this Permit to the ' trar
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.