Centerbar, Helen 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,LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No..._J...
Dist. No.... 3':9�+__ County _ONEIDA .or City MARCY
(If city, give street address)
Name of deceased._._____-Helen Centerbar T _ Veteran No
(If veteran, give name of War)
Female Single,;married,widowed, Single
Sex _ ____._.or divorced (write te word).____________..........__Date of Ti th. _i.-- 19.;�-�
Gle Falls New Irk
Age-_.._7,1 .Year _ �,_.........._M_Months. ��. -_.__Da Birthplace.._..._...
Cause of-Death_____-------� .L¢i- - - _ -.. . . .�s�e� <L. �C` icoS .............
Certificate was signed b .--...--_-_ 1 ---.�__.. M.D,
g
Address_ �` 1 .1 - Xi
s ....._....
Place of Burialor Removal)...,_ ._ ./ .. . 7.11:.�
(If body is to be t..tteen�brarily II in spa - lasso)- C •---
Cemetery-.---(-Al�,e�2 _ � _._.._..._._....._..Date of Burial_ :-_ ... 19 ,
(If body is to he temporarily held, fill In space later)
The Certificate of Death containing the Bove stated particulars, having been presented to me, fter 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
Number, and -on a basis areal I HER BY GRANT A PERMII
( ame) d ess
/44*%
the..___ _______.____.__ to hold temporaril d_--_._.. ___...... ___---__.the body
( ntierttker or per having charge of corpse) (Inter,rem e, or ktberwi ose of [state' mod)Dated... .!..2',.._ 19_:: .' (Signed) 'e� 1, -.-J"(rRA_
Local Registrar
This Permit i sufficient for the Removal (and Interment or 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 was- 11 C 19__C.7
(Interment or Cre ation)
1.41---4-- (Name a of Cemetery,Crematorium, etc.)
e,s(j2":7/eC - 7--;A,-71-::
Section, .' t No. Grave No�J
.7'. 'f-7 _
(Signed)
(Person in Charge)
4TAddress re_.. 14`--V2—,---
Person in charge must return this Permit to the Re trar
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.