Sanders, May 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 C -
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
egi/steed Ne.
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Dist. �,'d;5� U/ County��1...�:... . ... - or City 6
(If 't , give street address)
Name of ased C"-t-... Veteran
(If veteran, give name of War)
SI le, married, widowed, /y
Sex..,.-�2. . or divorced (write the word ,Date of Dea .,� 191,
Age P Years. Months ys i Birthplace
Cause of-Death 7,......
Certificate was signed b '!"3S M.D.
Address .. /32
Place of Burial (or Removal ....._....
(If body is to be to a ilvAteld, fill specs ii,;::4 .
ff r'
Cemetery y Z-7-..,„„2 .. u.��4/ Date of Burial //( 1f /
(if body is to be temporarily held, R 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 or r tration, have recorded it in my Lo 1 Record witja t above stated Registered
Number, nd on the basi here HFRABY GRANT A PERMIT /
Lej
to ' _.4: '' 4.e..._... �---e --•
ame ! ddress)
the �? .... . to hold temporarily and the body
(U aker or upon having charge of copse (Inter, remove, or otherwise dispose of [state how])
Dated /' 1t/ (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, 6/63) (3A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS CAR
CREMATIONS ARE MADE
Date o / JJ (t 2>ti-- - was ( ( 190
(Intlrment o
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z.
�� .-//.-'- ,c(L—(---6--//".„ 2
Nam Cemetery, Crematorium,(Name of etc.)
Section — . T.ot No. Grave No.
(Signed) - Z` -c—,/� J`�-r7 .` ` (-
(Person in Charge)
Y 6 A l� �
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.