Vaughn, Baby Boy NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
L_ ' 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. 7
Town, Village rister No.
Dist. No.`... ` County �,tO. 6�"f�- -- or City
, '. Vr
(If city, give street address)
Name of deceased... 4 �'`'�` Veteran
(If veteran, give name of War)
Sex /1!�``a1 ,, Single, married, widowed, •
^�� or divorced (write the word) Date of D t ___. ,,, (. t 19.6 ro
Age Y rs Months Days Birthplace-.-. .. 1
Cause of-Death i-Q-'� .(
Certificate was signed by M.D.
Address t
Place of Burial (or Removal) // . _ �-e-- - , rit iti
(If body is to be ran* held, fll'l t space lat ) ---
Cemetery �� Date of Burial 7 19 ‘ 4-
(If'body is to ge arity held, fill 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 Local Record with the b ve stated Registered
Num er, and on the is thereof I HEREBY GRANT A PERMIT f n �y� ,2 /
to CI 4A f`L�-`� 1a U i
( e) (Address)
the t to hold temporarily and the body
ndertaker or person having charge of co se) (Inter remove, or herwise disp se of [state how])
Dated // 19,i2 (Signed)--_ _ �j
Local Registrar
This ermit is su icient for the Removal (and Interment or Cremation) of a body to any part of the Atate (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 —Z.— • was- 19
(Interment or AtEff4a et)
' L. (Name of Cemetery, Crematorium, etc.)
Section_h Lot No.y/ 6 Grave No. A
(Signed) __ ✓' "' 1. e ) �'�C
(Person in Charge)
Address tf dt L (/?J�¢/�.✓. a �,
ItY
Person in charge must return this Permit to the Regis
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.