Montgomery, Zoah 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.
/0/ a ,v,, Town, Village,may,, egistere No.
Dist. No. County E"' or City r1✓f
e-.),...0.4;c4..e ata,,,,
(If city, give street address
Name Gin Veteran
of deceased
(If veteran, give name of War)
Single, married, widowed,
Sex �'"`l or divorced (write the word) ` Ow-e Date of Death 62444 ' 1162191 G
Age 9.-7 Years -- Monts., Days Birthplace 21e7e.,i'l-0- �'
Cause of-Death (,1..(.id"'"i'ee/iv- C � �-,°-'-✓ a,...
Certificate was signed by oC!*�'1j,me,, "�..2• ws.L4l4't �� M.D,
Address , . (�4�a:'.'!- t 'ry`�
Place of Buria ,,•r Removal). Q'e' 1 .
(If body is to be •oraril �a,�II i space War) C �.. 6
Cemetery4+ ' y i 4.P t444 Date of urial �" 19...b_
(If body is to be temporarily held,fill to space later) 1
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 ccepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numbe a lin the basis ther f I HER BY G{irN,�NW PERMIT n p 4 e jeo-tigcli
/)to tt-�i�-V-Gi.v✓ bpi-e II L lici. v y-. �C I �c. al�.tse
the ZI. eg' � T- I"c- 4cilA*5 hold temporarily an `,Me-ct. .the body
(Undsstiler or person hav charge of co J) (Inter,rem , or otherwispripos Ti ate ))
Dated /p..a s t 19..(t?. (Signed) ��74-�s"" ' ' :7 ' __ .�/�_
// / Local Registrar // 7-
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject '
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) is req\
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 19___
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section + Lot No. : "" ' ), Grave No. 9--
(Signed) _ p
(Person in Charge)
Address , .%
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 THE FIRST OFFENSE.The law
will be enforced. Local Registrars are required, under penalty,
to report violations thereof.