Boss, 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Rip stered No ,.;2 Dist. No�.S7 Count Ty� I '
•� a , (If city, give t et addres
W Name of de sed - Veteran 1 0
'` � '—{. •
(If veteran, give name of War
Single, married id wed,
Sex or �"
divorced (write t e word)... Date of t $G? {Q
Age--- -- ----. ears-- onths D ys in lars----- -... .. r . ..
Cause of- ath.. .. .... •. — lJ
Certificate was4n,e .. ....... . . NI.D,
Address. ..... ... ... 1.
Place of B1.0(or e, • It
(If bodyis torar h 1 space late
Cemetery. P
Y � - - -- Date of Burial 7 c 1C..
(If body is to be temporarily he•, I In space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW
I have accepted the same for registration, have recorded it in my Lo ecord with the a ve stated Registered
N ,ei, and on t. • b.,- thereof I HEREBY GRANT A PERMIT
to r - ' =:
•
r t U) ddress)
the ..... • • to hold tempor�ril and the body
(Undertakerf c sej ll�rr�� (Inter, r ove, a or therwise dispose of [st ow])
or p rson having charge oDated c. — 1 (Signed) • 1..t,. a• . ,`
Local_Registrar 1
This Permit is sufficient for the Removal (and Interment or Cremation) of body to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 62) is required.
Form VS. 61. (Rev. 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of ' '~' . .._was G' ` c� / v —19_ Y 6-
(Interment or CLr ,�.)—
. 7/ ,„ (--i
4_ ,z , ,___
_,
_.... , _
,_ 7........42. ,:,.... .
(Name of Cemetery, Crematorium, etc.) /
Section - Lot No. Grave No. 7
(Signed) _ / L.=-$_ G t..- e ? 2..L C ,___ ►-
(Person in Charse)
Address 4'.--.‘ -< L./e V ! ..`_/
Z,
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 FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR ''HE FIRST OFFENSE. The law
will be enforced. Local Registrars are required, under penalty,
to report violations thereof.