Mabb, Yvonne NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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.
Town, Village Registered No.
Dl5 SCHENECTA,2,
„.10DY g
sI. No.. County .or City DISK A A
(If city, give street address)� p Y
Name of deceaseC� �T✓Y'.1 ate. Veteran
(If veteran, give name of War)
Single, married, wi wed,
/�?� or divorced w ' e word Date of Deat .� �� 2
Sex.. -1 .G�.�K ( :.yr(
o B irth ace NIS ,
Age ...M �`l �11 .AY, �}.... . ....
Cause of-Death �r �["
Certificate was signed �.7. x.4`,�, w M..D,
Address .ls{?.. " �1 T � �
Place of Burial (or 'atioval)... .�•� ,i - .
(If body is to be tempo sr'. i if fill in space er) 19 f
Cemete ..- �� Date of Burial /
(if body is to be temporari y held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation,,the s me appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED Y LAW,
ave ac t d the me for registration, have recorded it in my Local Record 'th the a e state . Regist d
m r, to n t asi the of I HEREBY GRANT A PERMIT - n
, 9
ddressj
t ._ ( ... . to hold temp alibi a d t e bod
(Und ak ha e of (Inter,rem r otherwi e ,,state ho )
Dated_ •` er r rson g c r 1 ...p� (Signed) -e-4_ ,. O ,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the tate (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) (3A2.333)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date yf2�'u s was 19_ 6 7
' ment or Coma6tett)'
,c-,..,* 4 __ed-7 .1..,.._
(Name of Cemetery, rematorium, etc.)
.1
......__
•
Section_ Lot No. Grave No. _
(Signed) r
(Person in barge
Address .. C C r-% r- _.:
-- /7 ,
Person in charge must return this Permit to the R istrar
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.