Cameron, Harriet NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
EtSr 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, LE BLY WRITTEN IN DURABLE BLACK INK.
Town, V`ti}xge istered No
Dist. No Co Co nty. `�'�'�- v>-Eity �
.. (If city, give street a ell
Name of deceased. 1" ....2. Veteran
-� '� (If veteran, give name of War)
Single, married, widowed,
Sex......•.. .. or divorced (write the word) - ate of Death — 19 .
Age A7 S.. rs... onths Da B' the
Cause of Deat
Certificate was si ne by ��
Address
Place of B . 'al (or R-•+i:va 41...
(If body is to b� :11 . aril ��ftll spats ter)
Cemetery... .. - t+.�,, 6 196
• ,............Date of Burial....
(If body is to em•orarily hel•It I 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 ord wi,, the 40,ve tated is red
Nu , an n t base e of I HERIDY GILAITT PERMIT i
to -- .
- Q.. o.,5'A ..3 Y1
� (Address)
the ,... .. ., to hold temporar' •�... th o y
nde or,person having charge of co se) (;er,remove,or�se of [state how])
Dated /..ti/L 19��.'. (Signed) . ,�
Local Registrar
This Permi is sufficient for the Remo 1 (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, 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_____
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section_ (-1- Lot No. // Grave No._....,9
_
,..
(Signed) ---______ A`--"'"
(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.