DeLaine, Odena NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deput., ,. bubregistrar) 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. (‘7/
Registered
/ Town, Village , f. jj
Dist. No' �i.C/.. Coun -�(" LrG�"`.--z cc_,•2
..�....or Ci ...�
�' (If city, gives eet address)
Name of eceased .G.. '. ...- .etLeLeVA--i Veteran
(I/Veteran, give name of War)
/ ' 1 Single, married, widowed, / 7
Sex �.�jj ., . or divorced (write the word)...�.1. -:a�-�.,rY7ate of Death —�-e..... f .. ... 9..4‹
Age ( ,r!�.� Mont Days Birthplace.
Cause of-Death � '
Certificate was signed by . .i-�.. .. ... . M.D.
Address ,.. .. l-
Place of Burial (or emoval) .. t-, ' rt-�--
(If body is to be tempora ly eld, flI sp I or)
Cemetery ":.. v. DateThi Burial i ..;::4/": .;5r. 19. ;
(If body is to he temporarily held, fill to space ater)
The Certificate of Death contai ng the above stated particulars, having been presented to me, after careful exami-
nation,,the same appearing to e COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Re r with the above state Registered
Number, and on the basis there f I HEREB�GRANT A PERMIT /
to' . �, Zcc�i r�s 1
(� (Addre
t 4 �- :.. to hold temporar' an .... _ ... ... the body
(wake or person having charge of core )/ (Inter,re ve,or tithe se dispose o� [state how )
Dated a 7 19 (Signed) 11l„J
C ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a 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 --Ztt..m +lrM --/-12 -- 19_‘7
(Interment dr et itiatfon)
040..eg_
(NdHie 6 Cemetery, C-filiatoriilni, etc.)
Stotioo_ — - Lot N®-"-" -- arav@ Mtn._ __
�
(Signed) v • - � -� ���'
=— _
(I3er§6ti is CitarRey
Address
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS front abu e date. If fib
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.