Orcutt, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Eel' 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.
Town, Village Registered No.
Dist. No. Q.1 CountyLW or City '�.% ...k
/ ; . (If city, streett7,address)
Name of deceased. .. . J Veteran /!
(If veteran, give name of War)
Single, married, widowed, /Q 1 `
Sex or divorced (write the word).-_. . . ate of th... 944
Age :.. Yea �—r Months — ay " Birthplace v � 1 ..v
Cause of-Death_._. i:... ....-
Certificate was signed by a. ., M.D.
Address
Place of Bur' or Removal) � ..�_.
(If body is to ararily h 11,in space later) y
Cemetery.. .. � �. -/-�- % .-- - , .,._ ..., Date of Burial � �,.1. .`f..�.._.... . 19G4�
(If body is to be temporarily held, fill In space later)
The Certificate of Death containing the above stated a iculars, having been presented to me, after careful exami-
nation,,the same appearing to be COMPLETE, CO -CT, AND SATISFACTORY AS REQUIRED BY LAW,
I have; accepted the same for registr tion, have recorded it in my Local Record with the v state ,i tered
Numb r and on the basi hereof; BY GRANT A PERMI
to. ✓. t c % / .�' � e.44
the A(Name) ' 'Ad rests
l----.)-- ..�/" ` />- temporarily and the fy,hold
(Underta�l or copse)
person having charge of cose I er,remove, or other se�Hyepose of [st to how])
Dated . . .. II 19-.1...'i (Signed)
local Registrar j. 71
This Permit is sufficient for the Removal (and Interment or Cremation) of a body t any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a T nsit 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 /. -/ • was 1- /y• 19_ w A-
(Interment or Cr mation)
C!i�� /7�tee._ C(i2Jii..
•
(Name of Cemetery, Crematorium, etc.)
'-'-- 4.L1 eh ,i2(i
lie
Section 4]St-No.—_ .__. Grave No
I / /
(Signed), _2_lt 4,-A� _ _�y -e-:e--- -L. ( [L.
(Person in Charge)
Address '(f; ".r .. 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.