Butz, Peter NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
/� Registered No.__A_�-ll
Town, Village Q�:C.�. .._-L7-�'�Dist. Na _-_j—Cal County.._ _, .a-rx _ or City
_ / (If city, give street address)
Name of deceased v,v�x" Y Veteran -
(If veteran, give name of War)
`-1_ p Single, married, widowe , c `��
Sex /G� i-_ or divorced (write the word) Date of D th_-_..-_! 1. A 19_4i
Age I 3 Years. Months-. Da s ,Birthplace_-- •-••
Cause of-Death..
Certificate was signed by Z M.D,
Address -
Place of Burial (or R val)__., , )'2_ ltt fr
(If body is to be temporaril Alt
�fillp ins .�""'z[ 6~Slater) /l� / /
Cemetery .. 1-4. Date of Burial 7 19cL
Of body is to be temporari y held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to after careful exami-
nation,•the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have acce ted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, on they apthnHEREBY GRANT A PERMIT Qto
ZeilA 4ZI.u.
� _ p�.0 A (Address)
the .__ ... __ to hold tempora ' and -4-x the body
(U aker or person having charge of co ) (Inter,rem ve,or other dispose of state how])
Dated )- 19 C (Signed) !'i,lAiL
Y Local Registrar
This Permit is ufficient for the Removal (and Interment or Cremation) of a body 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 A--1( -_.. was /e- 4/ L / 19_ ‘ e-
(Interment or Cremation) /
7A
- 1 ,_..., ,, __ 1
_.., Lt
(Name of Cemetery, Crematorium, etc.)
/ . t
Section Lot No., /74 Grave No. _.__
_ ,�
(Signed) _ 1! /'`- V`/ ., z ( Q ,(Person n Charge)
g )
C
Address / f �--.%..Gc...�. �" 4- 1. _..
1f
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.