Hamelin, Anna 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. ,��j
��// Town, Village istered No. i:j
Dist. No.. r Coun .C�Cyre-re — or City, i ��
,�^ (If city, give street address)
Name of deceased . :,Y 771 ✓,?.... r.2Z:2 Veteran '
(If veteran, give name of War)
/� �fj�Single, married, widowed,Sex ( cc—a.- or divorced (write the word) .e�'=!- t:? -____-Date of th )-Z-ii/ 1 /7 19..C,
Age / Yea ,e. , Months L° Days in c Birthplace.__.. .. �.�7.a... ... y ..
•
Cause of-Death rS.J -,e...-e-
Certificate was signed by 941. ; -4- � k M.D.
Address .,,c.' . . (_,"
Place of Burial or Removal) .... ...........e.2.4�L. '...:.: :ft. - ��C-
VL
(If body is to be to o aniy l , 1 ce later) /� '/
Cemetery ' _ C t �� .�.. t-f, 't't - Date of Burial LitCr_ 2..I 19 el
(If body is to bet mporarily held 11 in space later)
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 the above stated Registered
Number,/azid on.the basis ,4therreof, (3 HEREBY GRANT A PERMIT .,
to G.-= 1 s_.�z-.;.. ...:. ---"--h- '�--- �rv�-�'4".. ✓} *7
Name) % (Address)
the to hold temporarily and.—.... .. the body
(Undertalogfr person having charge of corys nteq/eltt otherw' e dispose of [state how])
Dated :� .:2
. ...0 19 (Signed)- a 6 .. ,L,_,
l ! o I Reg'rar
This Permit is sufficient for the Removal (and Interment or Cre ion) o a body to a y part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in whip 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 U 1 ti was it <-' 19
(Interment or Cremation)
(Name o Cemetery,Crematorium,etc.)
Sectio •2 Lot No "3 Ni 14 Grave
(Signed) _
(Person in Charge)
•
Address
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.