Mattison, Bert 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 .. , ; % Registered No.
' �J County. . .�. orT CityVillage rUYf K ti. ,
Dist. Count or City
(If`city,
y, give street address)
Name of deceased ---7 ,�!ll� //Vd... .. . Veteran
(If veteran, give name of War)
Single, ried, widowed, r o
Sex � A.
or divorced (write the word) //& ,� Date of Death- / 1'e7 196'7
Age 9 S Years. -,...._Months Days Birthplace
Cause of-Death !' .�
Certificate was signed by...- . -_
L n M.D.
Address 3 - _....... . ie.c -z , '/(
Place of Burial or Removal ) r --
(If body is to b e p raril helIp�,,fi�f i space la —Cemetery ..1/ , Date of Burial..-. . / /q
19 7
(If body is to he temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been Ares ted 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
Numb n on he/is= HEREBY GRANT A PERMIT /2z— i j
'
ate
the.... ... _, -, to hold tempor. ' y and...- _..._ _- (Address) vf
the body
Undertaker or person having charge of copse) (I r-,remove,�y� or otherwise dispose of [state how])
Dated._. /4 19 67 (Sig ed). 1`.. ` eiu-,r.4
Local Registrar
is 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, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date as w- /
9
Z LG me -1 �
11�2C (Name of Cemetery, Crematorium, etc.) J l
Section_—_ 7 Lot No. Gt/3ave No.__7
i I
, Z
(Signed) _ C-li'k /�-1 / CL
(Person inj(:h'arge)
Address
Person' charge must return this Permit t the Registrar
of his District within SEVEN (7) DAYS from ove 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.