Colchester, Herbert 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, LEGI LY WRITTEN IN DURABLE BLACK INK. /1
S Town, Villn8rt, :ee
gistered NoDist. N _-.. .. County c wt add s)
Name of deceased .... ! Veteran )l_
(If veteran, give name of War)
Single, married, widowed, -
Sex or divorced (write the word) � 1%Lf. ' Date of Death.--!o -,z - 19.�7
Age--4_J Y s Months Days Birthplac . '. .:...t2�s��:
�.. ,� 5 r-1--�
Cause of-Death.... -0,-
Certificate was sign by ,. M.D.
r
Address--- .- .....-:_ .0 -4
' -Y -
Place of Burial (or Removal). _
(If body is to b porarily held,RIllin,space later)
Cemetery. ...,_ - -+- -' .c. a r ,... -. Date of Burial /U =- `5 19
(If body is to he 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 LA\V,
I have accepted the same fo egistration, have recorded it in my Local
%RReeco'rd with the above stated Registered
Nu a and o the b s• t,�.of I HEREBY GRANT A PERMI < '` - '/
f
� ^ � . — -r
the L f� �-%-c-, to hold tempor i and �._�'.a) t e ody
/ derta r orof corpse (Inter, remov therwis tsp a of [state how])
Dated - - ers n having charge 19(a (Signed) .__ e
ocal Regis
This Permit is sufficient for the Removal (and Interment or Cremation) of a dy 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
ram..
Date of//'4yz.•,.Lrrnent
was K --- 19_ 7
or Creestttmn)-
,./I ----C'- '71---' -
(Name of Cemetery, Cdematorium, etc.)
.k-i.----"'''fr
Section "✓ N71 Lot :4 Grave No._._7
4
(Signed) -/ l ,- z i (
(Person in Charge)
•
Address ,L c i µ` /'��—���.
Person in charge must return this Permit to the Reg trar7
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.