Conklin, Eliza 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, LEG BLY WRITTEN IN DURABLE BLACK INK.
Town, V tt'Iage ' istered No.
Dist. No.. .... Counnty.. ...... ....
(If city, give stre a
Name of ased ti
,. Veteran U `"T�� (If veteran, give name of War)
In le, married, widowed, /�
Sex.... .. .... or divorced (write the word) Date o th ..�.{}'� 19(0..
Age _0 l Month, ...Days , e :in 1 c +
Cause o ath.. .. . — .- �,�
Certificate was si ne by I .-_, ¶ " '� i M.D.
Address... ,;re
,, �, •
Place of Bur' r Removal).+ . '.'. -�
(If body is to b temp ai y held, fill i s• later) /`
Cemetery „er ..... . ,' . ..,� Date of Burial q /9 19c7
(If body is to be a porarily held, ' I In space later)
The Certificate of Death containing the above state. 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 pted th same for egistration, have recorded it in my Local R or with tatahoy Ao. ed Regi red
Nu d the b. -is . f I HEREBY GRANT A PER (� // �
-
to... .. .
e) '(neress)
the 4. - to hold temporari i the
(Un a ker or person having charge •f ?erps (Inter,remove, wise s of {state how))
Dated .... ? 1t (Signed)
I Local Registrar
This Permit is sufficient for the Remo al (and Interment or Cremation) of a bo 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
r.
Date o �Z ( w )� �/7
Interment or remat' n/�
•
(Name of Cemetery, Crematorium, etc.)
Section_ -- Lot No.77 / Grave
(Signed) - s� � 41")1
(Person in Charge)
-�L.C
Address � rb �` �`
0/..
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.