Merritt, Orson NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
aim 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.
r ..0 Town, _ r�_istered No.._..;-9
Dist. Na. . .. ount er city--
(If city, give str t addres
Name of deceas d........ ..... r .. Veteran .
(If veteran, give name of War)
Single, married, widowed, a
Sex.... •-- or divorced (write the word). f `-P4 Date o D th.-: .- 3 a 19..6
4
Age. c earsonths a s Birthpl e `.. ...
Cause of-Deat ` .. .
Certificate was signed Jay , `..4 L , .... M.D,
Address .a.," -
Place of Buri r.Remov 1) _ �'�
(If body is to b te��po arily held, II i space ater) /
Cemetery 4i a ._.� .��3 Date of Burial .... 19_l a
Of body is to be temporarily held, fit in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, fter careful exami-
nation,,the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have .ccepted the sa for reg. ration, have recorded it in my Lo Re•rd ith the boy stated R�� �g1Steed
iY in th 's thereof HERE ANT A PE I 7 (�[j
e) i} (Addr ss
the '� to hold tempora ly� Id ei 1.a ody
Und - 'or person having charge of co s (I -r,remove r o er se di ose of [state how])
Dated '• - 19 (Signed) _..
cal'Regi rar
This Fermi l is sufficient for the Removal (and Interment or Cr ation) of a to any part of the State (subject to 1 al
cemetery or oth-r 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--" --2-_ /, was r2/rc' ,--- 19
(Interment or Cremation),
1 r r----�.'.,_ ....-
(Name of Cemetery, Crematorium, etc.)
r^..
Section___, cif T,ot No\'v er Grave No.___/
(Signed) - rjl,.�_/�- G..� _ ,4 ' G!s7.2.,
7 (Person in Charge
Address ,> ( �..: `�G--L 2 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.