Lash, George NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Llgr 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, LEG BLY WRITTEN IN DURABLE BLACK INK.
(� E l Town, Registered No.
tr
Dist. No. .5_YJ 7Cotl . 'i*•'!!„1j or City "`�'i7
(If city, give sheet address)
Name of deceased ... eirae... .. ,,. Veteran
• (If veteran, give name of War)
;i Single, arried, widowed, ! (}
Atcci
Sex_-. _ or divorced (write the word).... Q-c Date of Death. "1.-...) 19 CC-
Years (Months NI Days Birthplace
Cause of-Death. ._i
Certificate was sign,. . --. yj... .- �. ,- v M.D.
Address ... .:. 1..
Place of B 1 (or Re .v.l)
(If body is to e e p ari1y in s‘(o later) j /'
Cemetery ) .a:,r�.. Date of Burial 19 .1v
(If body is to be temporarily held, tii 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 cal Record w' the above stated Registered
N nd on the i thereof )� HEREBY GRANT A P MI .4S �` On
to i--r CCCC _
' /Name) ress)
the -v ' �--- to hold temporal' y an ' the body
Undertaker or/person having charge of c pse) (Inter,remove, of disp e of [state how
Dated ., 19 -.�/•/_ (Signed) =- 2t-1
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cre ation) of a body to any part of the State (subject t cal
cemetery or other regulations), unless removal is by common carrier, in which case a ransit 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_____..
(Interment or Cremation)
(Name of emetery, Crematorium, etc.)
f eebion_ Grave NzT
•
(Signed) _.—__ /7(S/
(P ,erson i arge)
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.