Buckwith, Buel NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
p 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 R-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. �U!!
1 j d N tare
Dist. Nm 0 f::. l County._..1� or City ..._ 6- 1.
,� / (If city, a street address)
Name of deceased 6 �ll.�.... -c--L y` Veteran
(If veteran, give name of War)
Single, married, widowed, �j _ G 9
Sex.______._ u or divorced (write the word
ate of . ttl�.. ��- 1
Age 6 ..._Y it r__/_ Months . . Days Birthplace. .....lf'y��^,.`.
Cause of-Death.--- -• P w..-- :... .._
Certificate was signed by M.D.
Address r 7 C.- try
Place of Burial („or Removal) 77.14:-•,(If body is to be temporan held, fill in rCemetery .- , .� Da of Burial 196
(If body is to e temporarily held, fill in space later)t
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 th ove stated Registered
N , and on t ,-..' i ; eof I HER Y GRANT A PERMIT //
(Address)
th •Al.-. v to hold temporar' and. the body
(Undertaker or person having charge of core ) (Inter,re ove,or of wise dispose pf [state how])
Dated. — 19 (Signed) (� '��/
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body any part of the S ate (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 OR
CREMATIONS ARE MADE
f
Date � z-- was�"a/�'.. ,7` 9 19_ C
(Interment or t'.'Tem/an:4f'�.� '
2 _
( „„,_(
,/,..,,_______ .•_„ ____,_, ,6,--,_.
_ z.--
(Name of Cemetery, Cremator' m, etc.)
�_ :
Section_—_ Lot No? Grave No.__'-5
(Signed) _ Z, '- .7'� ...{ / C L
(Person in Charge)
T
V' !
Address r L pi-- ...,,,—,, C �..— e ,
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,
io report violations thereof.