Balduc, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Depot: i 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. RegRegistered No.._..3
Dist. No;-..,4P..Qff. County...CC) or City eet 5;,,--.� t
(If city, give address)
Name of deceased... Veteran
(If veteran, give name of War)
Ingle, married, widowed, �
Sex. or divorced (write the word)f/( ..mate of th l 19.6,2
A ears... •-- olz... Days r� Birthplace.. ...... ... .
Cause of-Deathhh •• -• - ••
Certificate was signed by.. . . .... / c.....,ll..../ M.D.
Address ....
Place of Burial r emoval). ..
(If body is to be to or ly hel 1 in ace let
Cemetery.. .. .... ,........ . . . .• a e of Burial /-- 194-g
(If body is to be temporarily held, fill In f ce later)
The Certificate of Death con fining 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 eco d with the ove stated Registered
Number and on the 1; rt r of I HEREBY GRANT A PERMIT
(Ad ess)
the to hold temporarily an the body
(Un maker or erson having charge of copse) , (Int , tryoyeq or otherwise dispose of [state how])
Dated / `._ 19.ar.7 (Signed)
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, 82) is required.
Form VS. 61. (Rev. 6/631 (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qt
CREMATIONS ARE MADE
•
Date of- - was
(Interment,or Cremation)
1, ,
(Name of Cemetery. Crlft*Mrltn4--etc.)
Section-__- J..l., toLNe. Y Grave No,
(Signed) — —
----------- erttfit'i5 CNatge)------
Address I ,
Person in charge must return this Permit to the Registrar
of his District within SEVEN (it) DAYS froth 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 "fTO person in charge," and FILE
PERMIT WITHIN THREE (3) f)AYS 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.