Johnson, Harry NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(a ' 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 WIIITTEN IN DURABLE BLACK INK.
Town, Village`s l Registere�dyNo.
Dist. No,.i-Zt 2/County.............— 'a -- or City 1 to-,'Z--
(if city, giv trees address)
I G�
Name of deceased -----.- -____... ., Veteran
(If veteran, give name of War)
Si le,:married, widowed,
Sex . or divorced (write the word). Date of th. 19 6'
Age Yearlocnths...., 1s Bir ITylace w ?' j' •
Cause of-`I3eath.._._._.. ..... _ .._ ...._ ._. . .. ... . ,
Certificate was signe k ..,.`! �►� �? .l M.D,
Address c%/-�'k-- .,..- '�,'� �,
Place of Burial (or Removal)... :-(.�
(If body is to be temporarily held, fill in space deter)
Cemetery , Date of Burial — C" 19 67
(if body is to he temporarily held, fill in space tatter)
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 regi_ ation, have recorded it in my Local Record with the above stated Registered
Numbe and on th s tpigreof: ,EREBY GRANT A PERMIT , 7"
to •
�J pre
e) ' dress)
the _,_ ?_.. __... to hold temporarily and ---- the body
(Undertaker or,perso having charge Of corp ) (Inter,remove,or otherwise dispose of [state how])
Dated — /9..t... 7 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment ox 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 qR
CREMATIONS ARE MADE
Date of 'JZ'"""7Y` '� w 19
(Interment or n)
(Name of Cemetery, Crematorium, etc.)
Section_ Lot No.,7/ Grave No.—_.
(Signed) -Zi" �L t-
(Person in Charge)
Address J L ` ` L j!
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.