Nelson, David NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
aSr 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 C -
TIFICATE OF DEATH, LEGIBLY RITTEN IN DURABLE BLACK INK.
Town Vigt:" Registered No.
Dist. NoX �ount , 'L"z.--
t (If city, give street a�dyjs)
Name of deceased �'�, Veteran
(If vetety, give name of War)
Single, married, widowed, ��
Sex..
. ..... or divorced (write the word) Date of Death ,... 19.
Age-..- Year onths �y�s Birth a ,.
-��-c q-e- � .... .. . ...
Cause of-Death. K ✓
Certificate was signed b3,: , < ....- M.D.
Address-/7.C,�`�,'- �— , �:"
Place of Burial (or Removal)- , ,,..,. .---/--.. .•• Z4
(If body is to e t mpora' Id fi it pace later)
Cemetery. ! Date of Burial V,/ L7 1947
(if body is to 4e temporarily he I111 to space later)
The Certificate of Death containing the above stated particu ars, 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
Numb and on b the -s the eof I HEREBY GRANT A PERMIT_,
—'-' tee) (Address) -
the to hold temporaril and.... ; the body
(31,dirtaker or erson having charge of cow!) (Inter,rem v or p, se dis !SF[s`�ate ow])
Dated-.. . .fib' 19.677 (Signed)- .- - (/.�/Fig
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of bod to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case 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 5Z 401*-' was `, 2 r 19 6, 7
(interment or Cremation) /
(Name of Ceme ry, Crematorium, etc.)
Section Lot No. Grave No.3
(Signed) _
(Person in Charge)
Address •/^E 'er"
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 DIRECTOIS 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.