Harvey, Charles NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I 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 IT'i'EN IN DURABLE BLACK INK.
Regis red No. -� .-
7
Town, Village 01
Dist. No�� - C y_ or City - •• •
�1 (If city, give street address)
Name of deceased ��/�-ivv Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex ... or divorced (write the word) ate of Death �' �° ' i ik'6
Age__.. ... Y s Month Days , Birthplace..,.
Cause of-Ieath ..
Certificate was signed jit..
M.D.
Address.../.. .�.. . .
Place of Buri - or Removal ....... ...... .. ............. .. .
(If body is to h to (warily he d, 1 i apace la r
Cemetery,.. ,.C.�- Date of urial.. ' �a`1 19.ho.
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated rticulars, having been presented t 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 Re rd with the ab ye stated Registered
Numb r, and on t has' reof I HER Y GRANT A PERMIT to. i ,. `, ff/
T I 1.11
a
th ..... to hold tempor wily and - he bo
ndertaker or perm ving pp charge of co se ; ` (Inter,remov h wi ispose of [state h
Dated_ • .a 19 (Signed)
Local Registrar
This Per is sufficient for the Removal (and Interment or Cremation) of a dy to any part of the State (subject to local
cemetery or of er regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) 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- 7LZ2- " w�:�Z' ,1 19 �r ,
(Interment or rremationr
6,,„.2.2
J✓ (Name of Cemet ; Crematorium, otc.) .
wry, �
�'':2 -1, ` /7 e.4�>2./
Section "2 f , Lot No. ///1 Grave No.__,,,,
. ..._ . ,,_
(Signed) -- . �CGS a _-
(Person in Charge)
Address U r -? ('' C1-..—.
Person in charge must return this Permit to 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.