Clarke, Alfred NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qom' 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. 7
/ Town, Village Registered /
Dist. Now 4 / County Kl C`�'-��-�'� or City .�_ iu � �" �
j (If city, a street address)
Name of deceased ` O Veteran
(If veteran, give name of War)
Sex / Single, married, widowed,
or divorced (write the word' 17 1 Date of D th a` & 19 6 e
Age___ _.., Year .. Months a Birthplace......... — ,— , .V,
/
Cause of-Death
Certificate was signed by ... mac. ,.,-r_... .. . -: }: M.D.
Address ,•,>• - :,.:
Place of Burial (or Removal).....✓1•!4.--- r-- - . .--- ) G .r-A:L.- e_ ___(If body is to be temporarily a fill in space laterCemeteryti). "�/-fir„1 , Date of Burial , 19r.`l
(If body is to be temporarily eld, fill in 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 thereof I LH-O B " ANT A PERMIT
. (N (Address)
44r-�6
(
the ��/.... .. ................ .. ...y to hold temporarily and_ .. the body
(Undertaker or era n having charge of corpse) (Inte ,remove,"gr otherwis dis ose of [state howl)
Dated (-5 — 19_. ..ej (Signed).... .. . +�/
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bo to any part of e State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 8.) 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 aY-r, —
(Interment or on
"--../.:_27,,,,e,--.' a7,,,,, . _.../,--a.-- -
%t Name of Cemetery, rematorium, etc.)
"'/.�C-Go— 71Cs-c._ LC et --
-:., V - -//
Section_ g 4114 Lot No./y s8 Grave No. -2-_
,
71-
(Signed) f'
(Person in Charge)
Address 4V/e-y4 -
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,
o report violations thereof.