Hubert, Pauline NEW YORK STATE DEPARTMIN I OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit car ,,P signed only by the Local Registrar (Deput, .rr subregistrar) of the Primary Registration District
(Town Village, or City) '_:, which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CER-
TIFICATE OF DEATH, LEGIBF WRITTEN IN DURABLE BLACK INK.
// , .1 Thwn, Village
Registered No
Dist. No. ( A2.. cot, nt 6-6 lk-/' --• or Gity 1Z{ra.e) . "� )c -
7 (If city, give street dress) `
Name of deceased t?..ze l z4-4 71 Veteran
(If veteran, give name of War)
Single, married, widowed, ``�
Sex4-,--1-r,;(6,(-6-- or divorced (write the word) <Z� �ti% Date of Depth Z / / 5— 19.:6/-
Age ZSS' Years ...Months ? Days .. Birthplace '2/,::21.:Z u-Y'7tl
Cause of-Death y„' `"Z 1- •,.2CZet.e .2. _2-7 r4
Certificate was signed by LM.D.
Address I. --- L Z....22. .11/1.Z.Z71.
Z:Tr '1/4.-----2.
Place of Burial (or Removal) Z44 -4,:r 1t Al--C_
(If body is to be te arily held, fill in sp er) �, / J
Cemetery _ .Z!.lL. , . _..,_ . ' ..uc...� Date of Burial ��E'!l .1...,� 19E
(If body is to t e te orarity held, n space later)
The Certifica of Death ontaining, 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,And o the( b*sis there f I HEREBY GRANT A PERMIT
-e-t
�' Name) Address)
the .�' c 6: _ - to hold temporarilyand ��..t... t e body
(Undertaker or person having charge of corpse) ( tee ove, or otherwise dispose of [state how])
Dated ./Z.E'. /_(T 19.6.1 (Signed) .4.t.... -L..L_s. I,t.c i..
Local Registr
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part o the State (subject to local
cemetery or other 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,-/ • - - was __19j/(Interment or Cram on
(Name of emetery, Crematorium, etc.)
Section_*__ Lot No. Grave No.____
(Signed)
---
(Person In Cheep)
Address _ fit" 7 7a(4.
Person in charge must return this Permit to the Re strar
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.