Johnson, Maurice NEW YORK STATE DEPARTMENT OF HEALTH
OFFICCIAL 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 � p Registered No.___17 7
Dist. No. S Z 6 f County ---- a %7.9-C- A--- or City l,eC 44--
(If city, give street address)
Name of deceased :. C- ate. Veteran -1"1--10
(If veteran, give name of War)
Single, marrie , wid ed, _ • 0
Sexc-- or divorced (write the word)-.. —e'1 Date of�eath ...%.: 5...19.6�
Age �._` . Nears. ,.Months ',,...Days Birthplace.. !�4� •F. 2u.Cause of-Death '-- — a-7� -
Certificate was signed by ,._ ..,. . M.D.
Address •J.. _..,, .,. ..
)11
Place of Bur Removal) d-&fI,r.. --..� ...
(If body is to be a asily held, fill in-space late /
Cemetery -...0 /-cAL(/' ., Date of Burial 1-2 19Kz.,
(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 aboveo stated Registered
Number, nd on the basis,treof I HE BY GRANT A PERMIT L?`�— h�
to - ✓ •
(N/}mO) (Address)
the to to hold temporarily and... the body
(Unde r or pers�ofifi having charge of corpse) nte rem e_rwise 'spose of [state how])
Dated Yt�t ./cr— 19h..7 (Signed) 4:4...61x)-.
���� Loca egistra
This Permit is sufficient for the Removal (and Interment or Crematidn) of ody to an part o 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) (3A2-333)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS QR
CREMATIONS ARE MADE
Date w r19 C
(Interment or rem )
Name of-'(;emetery, Crematorium,etc.)
/172e e-6:11-1
Section_ • Lot No./ Grave No.1I
Si ned) _ L /i �f �`�C L:
( g
(Person in Charge)
Address J i4
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.