Potter, Lillian 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 CER-
TIFICATE OF DEATH, LEGIBLY�/ WRITTEN IN DURABLE BLACK INK.
r , Village Regi ered No.
Dist. No, � .c County or- i y J5Lt tt-Z .�
(lf city, give stre t address)
Name of deceased Veteran
(If vet an, give name of War)
Single, married, widowed,
Sex or divorced (write the word) Z -�tt 1 Date of Death a 4/ 19 C 7
Age tTlYears Months Days Birthplace. 772,1'1 .
Cause of-Death 7 fit Gs.P,
Certificate was signed by , ._. M.D.
Address � �, ...i,�_Q AV
of Burial (or Removal) ,. .. ................ 1.1•;. �n
(If body is to be tempora{' held, ft space late�J_ s ,,, �/
Cemetery [ .. .y�;?.... �L�L Date of Burial 19.2
(If body is to be temporarily held, fill in space later) ',4?
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 Record with the above stated Registered
Number, don he bass�h' th4 eof I HEREBY GRANT A PERMIT d
.
(Name) (Address
the-.--•--:-4-(, 1x?34-dat't to hold temporarily and . 4;221/A- the body,
(Undertaker perso having charge of corpse) (Inter,rem ,or otherwi tspos state how))
Dated - rs. 19.1t:.7. (Signed) g
L Regtstra
This Permit is sufficient for the Removal (and Interment or Cremation) o a dy t�a y 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
r
pate I was - 19_ •t
nterment or .remation)
(Name of Cemetery, Cremato ium, etc.)
•
Section____ Lot No. Grave No.
Ci
(Signed}) ___— � �!� Vim.. r�bt
(Person in Charge)
- .
Address ((�( ':,'"�_�.'(...�`_.
-CAL
A
Person in charge mus return this Permit to thee/
rar
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.