Dorvee, Frances NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
z1SF' This Permit can be signed only by the Local Registrar (Deputy or subre istrar) of the Primary Registration District
(Town Village, or City) in which the death occurred after the FILING and accep ce of a CORRECT AND COMPLETE CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 3 69 Li
Town, Villa
egi t ed No.
Dist. No L / .. Coun 7/,!.a.-Z � or City g.. �-• (If city, give street address)
Name of deceased .:��'/J-.t�C.F ./ Veteran 71e-
f vet n, give name of War)
Single, married, widowed, i/ -
Sex "''t or dlvorced (write the word Date of t ' - !7 19 7
Age__,_._ Year onths ys 2 • hplac .._- r.- _....
Cause of-Death__. .�� �,l �. Y
Certificate was signed by - -. - M.D,
Address Lem Z . . ,. ,. .. ..,c 771`y'
Place of Buria or Removal)...,r(, %r' - ...... -L �'L_ �f(/1 ,.-.%1.-
(If body is to bet ar 1 Il - space ter) `/
v
Cemetery t,.--- _ill.:?- .. s Date of rial. , 19k.
(If body is to he temporarily hp , fill in space later)
The Certificate of Death containing the above state'particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SA ISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my L al Record with the above stated Registered
Number azrd on thej,bsis t eo HEREBY GRANT A PERMIT ,
to /11- -.".4.-24-- ..-Zi.Z ' = d•-)-- t-le .c,Y el y
�/ (Address)
the________. 7 . . �,./ to hold tempor - and _ .. the body
(U dert er or person having charge of corpse) Int r, move,ore erwiseldis/po, of [state how))
Dated..
�f�� +"3/ 19..1P.7 (Signed) - - `� 1.��/•.._
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. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of rtit" was 2 19_ 6?7
(Interment,. C1..malort) f
r Centelzi
(Na a of Cemetery,Ll..,,a.o,V
Section_ Lot No. /I Grave
.(Signed)
( erson in Charge) /y
a+/
Address S
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.