Smith, Hazel 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.
Town. Village 6E6
Registered No._..S.K&
Dist. No. 3-6'Q/ County l� -- -``� or City - J e-Q—
/ (If city, give street address)
Name of deceased --ti�--'1'/axa k' Veteran
(If veteran, give name of War)
�i Single, married, widowed, �j
Sex.._//1H/' -�` or divorced (write the word)..f't 4-rt�-4 Date of Death 0 Cat 2-� 19 J
Age �,/ Years. Months J,,....Day s Birthplaces'' .
Cause of-Death (,t._...�e—✓r.4--c-c—,-- `wy ' f
Certificate was signed by '✓- -e.- . - M.D.\70. -a‹,--,--fu--r
Address '-v7 .
Place of Burial-(lyor Removal) 1:..�».... � . 7
(If body is to be brartly held, fill in,apace late
Cemetery t. li-....-c-t G Date of Burial - . / 19b..7
(If body is to be temporarily held, fill 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 Record with the above stated Registered
Number and on the basis t eof_ _HEREBY GRANT A PERM
to :::?...4-444,1..42-7S a i y 7 ,e
(tFafie) (Address)
the Z z z4.,. to hold temporarily and . - the body
(Under or person having charge of corpse) (`� ( ter,re e, or .th wise disp a of [state how])
Dated �1 - 19.6.7. (Signed).:: ..—.t- ,.. .tip-:........
L cal Re ' trar
This Permit is sufficient for the Removal (and Interment or Crema ion) of'a body to any p rt of e 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. 6l. (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 _ mot No. . Grave No.
(Signed) __. ' / - F ., ( -
' (Person in Charge) F
Address /7
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.