Eastland, Constance 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, LEGIBLj
RITTEN IN DURABLE BLACK INK. 13
Town, Vil}Rge Registered No.
Dist. No.45.42.. County .4);i,.> 14. or City
� �-- ? (If city, give street address)
Name of deceased r4:CJ A -�A.4
. :---C -v Veteran •-71c ..
(If veteran, give name of War)
Sex Y12-/chg-c-e Single, married, widowed, n
or divorced (write the word)-..-l4fc..G !e,Sl Date of th ... ..�{......... .... 19.6u
Age 4,.g`-_.._Years. Months.. Days Birt �.(a e... `}/,... .4
Cause of-Death _ .1�t... -. ,
Certificate was signed by ., M.D.
Address 49.1 ` :Y -'/ .�.- ..,. .,,
Place of Burial (or Removal) 4,c,sz .,.a_uz_... f.....1. .a_ .-.__... . s—fp-
(If body is to be tem fill:in sp ce afar) a J v7
Cemetery ,.....,Q �,N •Q.I, ,._ ate of Burial 7.._`Z 196.7
(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
on the ba ' thereof I HEREBY GRANT A PERMIT / 4 . P. .)-(2e,„(41 A ,
the WV. 4, _ Address011/ , . , to hold temporarily and 0'-_- . . __- the body
(U ertaker person,having charge of co s ) (I re ve o other 4, ose of [state how])
Dated 19.4r'. (Signed) .. �'A,- .- ,
Local •egistrar
This Permit is s icient for the Removal (and Interment or Crematio ) 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 ,�a.L C L was 719J7
(IntermenCar Cretin on)
(Name of Cemetery, rema"1:tonum, etc.) /
/64.y-z-4-0-.41
fd
Section_ " ' Lot N C Grave No.— _
(Signed) - _ d:l'(Person
. �. zy=((�
in Charge)
Address _ 71 e ---c._,
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.