Hanneford, Edwain Poodles NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ISF 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 COMPL/TE CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. R stered No. G..—
�`�,� Town, dirge_
Dist. No. ? Count
(If city, give st t address)
N ]e of deceased . .� iet-3 i.. rel.b.b..1,.-Es A H .t.- .. Veteran ��
(If veteran, give name of War
Single, married, widowed,
Sex... or divorced (write the word).. 1r - 4 Date of eath ' . .. .-'q
Age Y u....Months .Days Birthplace.. .. i ,
Cause of- ath.._. _
Certificate was tignkl by M.D.
Address .. . . .. . _, ,t..1�{ .. . . t'ar—�
Place of Buri (o �emov ) ,. ....
(If body is to be m r il, y� I in space later 1 t
Cemetery4, ___- .� Date of Bturial....J I DZ.?
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated parti lags, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REPUIRED BY LAW,
I have • :•to- the sa a for r t gistration, have recorded it in my Local r og with t 9a.;
46 ed Re ' red
Nu d 4.the b si t r I YEREB ANT A PER W f/� A`
� V� (Name) . . A ddress) t d
the-_ _. to hold tempora ' y id ,�p y
(U•dertaker or p son having charge of corpse (Inter,remove, TlTwise is f state howl)
Dated !. . -- ! x 1S�P (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or C emation) of a bud o any part of the State (subject t local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) 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 o �:r,( h.. I was_ ) /c3 19 6 2
(Interment orIrremsMiett
(Name of Cemetery, rematorium,etc.)
Section c 5 i - Lot Dfo. f '8' Grave No. :
(Signed
(Person in Charge)
Address
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.