Dye, Annie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(ISF 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, LEGIB WRITTEN IN DURABLE BLACK INK. Re ' tered ��<---
/ Town, Village /Dist. No.,5, .6.1. County...G �Gc�A-72.t,,--ram,,.-- or City . s..."..,(42,..
(If city, dstreet address)
Name of deceased �,' ------ ,?.2. , Veteran
(If vetera give name of War)
Single, married, widowed/"
Sex... .:_. or divorced (write the word) - ..Date of th ...:,.��'. 9- f
Ag Y ...Mon s.... .... Days • Birthpla •
-- Cause of-Death...
Certificate was signed M.D,
Address
Place of Bur'-- a Removal ...... . ,,. .
(If body is to - •• ilyheld fl i ace to er) 7 / �9 7
Cemetery. .. -. _ ... ..... ........... .. D.to of Burial....
(If body is to he temporarily held, fill in space later)
The Certificate of Death containing the above stated parti lars, 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 r registration, have recorded it in my Loc R cord with the abovF ted Registered
Nu lrei an on t a eof I HEREBY GRANT A PERMIT -('
N dress)
t --- to hold tempora ily and.. ..the body
(U a akergg,� person having charge of core ) (Inter remove,or he ispose of [state how )
Dated CP 19.. 2,6 (Signed) -S� rwise
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bod 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, 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 19_ ______
(Interment or'cremation)
7/ < ')/` -
--e 0 „....
(Name of Cemetery, Crematorium, etc.)
. 7
Section --- ,. Lut No. 6 / Grave No. _ - --
1
(Signed) I-- `=c ". 'a ,'' C.-'—L j
(Person in Charge)
9 li l
l
i
,r- f
Address ' r G ' .i r .. ( t^ //
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.