Daha, Dorothy NEW YORK STATE DEPARTMEN'I: OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deput .)r subregistrar) of the Primary Registration District
(Town Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPL TE CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. [
AA Town, Village Registered
Dist. No..Q��U( County or City
(If city, give streentrgss)
Name of"deceased \D°10,cato_c_o_te4 Veteran !�' CAJI
(If veteran, give name of War)
Single, marrie , widowed,
Sex.. or ivorced (write the word) Date of Death.,,/ 1 l 19 6 7
Age 7 Years. 7ir, Mo hs Da s Birthplace O
Cause of-Death ... _.... .
Certificate was sign b� rh M.D.
Address }
Place of Burial (or Removal) .,,,/,c? "�l
(If body is to bet po rtly hel II i pac lat ) ,
Cemetery . Date o Burial � / � 191a._�
(If body is to he temporarily held, fill In sp ce 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 Re ord with stated Registered
Num er, a d on th sis thereof I HEREBY GRANT A PERMIT 17
7
to (i `'�'�.
( ress)
the to hold temporarily and the body
(Undo aker or person haviqg,charge of corpse) (Inter,remove,or q erwise dispos of ]st a ow])
Dated I.St, .i...- 19.(97 (Signed)
Local R gistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pa t of 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 --_19_ T,
(Interment or Ci•emation)
(Naive of Cemetery, Crematorium, etc.)
7SettioH-- L of I d. Grave Nd._ _
(Sighcti3 ---- - -
(Person in C iarge)
Person in charge must return this Permit to the itegistiai
of his District within SEVEN (7) DAYS from above date. it no
person is in charge, the FUNERAL DIRECTOR or UNbER-
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.