Richards, Charles NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Cr 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 C
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village istered No.....
Dist. No:St Si Cou Ot2tLQNameof deceased W.,,.. Veteran
(If reran, giv name of War)
Single, married, widowed, , )
Sex )rX or divorced (write the word) a e .f Death. ...`g.. .-.1.4 19
Age o hs D B')A hpl: A
Cause of-Death.. t.. -...
Certificate was signed by _ ,..� __ . .-._.... ..... M D.
Address '["""' ...
Place of Burial, Removal) .. '
(If body is to :; &:: ::
flI in ;::: : .
/f1 ... �r.n-�' . Date of Burial flll�rt' •.
The Certificate of Death containing the above stated particulars, having been presente to me, after careful exami-
nation,,the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have pt the same for registration, have recorded it in my Loc Reco d with the ove ted Registered
Nu and ' $he-,ba 's g if I HERE Y iR� U PERMIT
R U
e) 4 ddress)
the ...__ ' :�,,i, to hold tempor nd ody
wire or pq n having charge of c se (Inter,removq therwis 's a of [state how )
Dated /.7 19. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or remation) of a ody to any part of the State (subject to ocal
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 i''l L. *as 66--2—r J �"" 19 6J
(Interment dr Cremation)
/ / ,,, '/ ' ' (-'7
Name of Cemetery,
Crematorium, etc.)
I �"
Section /7 Lot No. G Grave No.—_/__.
C
(Signed) '•'' C• � ./j (..�;.. ...,C �-z 2 �-
(Person ' Charge) L-
Address?z-
• -"�- -4..:.,--,-h- L..e---.____ ^_.'1/ _ ,_.,.._...-
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.