White, Eva 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.
Registered No.
Town, Vill ei,,, 4 r,
Dist. No . =
Countyr_s.k _ ) or City
_� .. (If city, give street address)
Name of deceased....._e z):C :.-•---- .._...1,0`�I-4-�-K.� _. Veteran
,. - (If veteran, give name of War)
Single, married, widowed, �/j�J
Sex_ or divorced (write the word},._!'-'-t- -.Date of Death �� i _ 19
Age._ _ _Years. ._Months.....____.........Da s Birthplace- ,.. � 7...
Cause of-DeatheL.Ltdd-- X-(__raz -- Aflai.2.17 C2r _i t-. 2e G� Y..
Certificate was signed by:_- ..:....:..: ......M U.
Address _ y r , ti.., ri.de
Place of Burial (or Removal)...,1C' 'r2'�,.� a -�: - .. .
(If body is to be temp a ily held, [� s s later} �/
Cemetery..—._ ----•-- (i --- _. e of Burial.--f1.- ._ 19.6_1
(V body is to he temporarily held, fill space later) I
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRFC1, AND SA-'ISFACTORY 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 on,the basis thereof X HEREBY GRANT A PERMIT -
✓ (Name, "` �t, (Address)
the......_.. cy_Yf,.Gkl�k z:2 4...., to hold temporarily and �X . the body
(U ker or person-havin harge of corpse) , 1t+ter,r ove h wise disp se of [state how])
Dated--`:'� g-'L�i ± ..� ..11:. 19 (Signed)__.- . .{Z .
Local Registrar
This Permit is sufficient 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. (Roe, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of _______—was_ _l9_to7
(Interment or Cremati )
VT`�"'
(Name of etery,Crematorium,etc_)
Section_ . _Lot No. _Grave No._ _.
(Signed) eir - A-
(Person in Charge)
Address j4) 4 ' free-Oti . --)7
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.