Philo, William 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_ Registered No. [iTown .
�21lCounty_ ,a. ) or City
Village 4 Dist. No. ___ __
—fr..,..
� �j �'� (If city, give street address)
Name of deceased.__.__..:C.„ �%11 +���l-r Q Veteran
(If veteran, give name of War)
Single, married, widowed, / �- �
Sex_____ 61 - or divorced (write the word) iG �- Date of D th//� " '/ ./.�1�..-->>19C-C
Age. ._._Y -_._Aonths Days Birthplace...., �.. ice....,n - fir. ..
Cause of-D t.th__.
Certificate was signed by ,--__ / _. _ .... _.r�� �4 _ M.D.4y t"
Address r, „-. z� Gfi,-��
Place of Burial or Removal) ...o! (-,,, 7e
(If body is to be ily held, - space later 1
Cemetery . .o h'�f._4t r' L.- Date of Burial .�l!L a -./-._cam 19
(U boa, is to tie temporarily held, fill is 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 above stated Registered
Number, on the basis ereof I EREBY GRANT A PERMIT
to
1-4/7-1:-
theI/
. . to hold temporarily and.. ,4'14.-, ' ,7V,Ae(address) the body.
(Under ,or person having charge of co ) (Inter,remov ,or otherwise-dispose of [state how])
Dated. .a-1(e-4.) ,l7 19.(d. (Signed) (�
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, 82) is required.
Form VS.6l. (Rev,6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATION'S ARE MADE
1
r
Date of � i( — —;•was-74!0-"+c' /` 19_ 'r`
(Interment or Cremation)
,I,L r / ,.._ -(-2.2.........._ (..]
CI
(Name of Cemetery, Crematorium, etc.)
Section_ Lot No 561 I Grave No. 7
(Signed) -` J c::-._--/1 - " e''v2- ((-C.
(Person in Charge)
Address C2 J ...
� —
Person in charge must return this Per 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.