Calkins, Norman 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 p Registe od No. .4.7.........
Dist. No. County L / `.� 2e .e" or City "`'``` . L
1 (if city, give street rasa)
7
Name of"deceased......L. .?? 'i - " `� Veteran
(If veteran, give name of War)
` Single, married, widowed, f /
Sex / t �`t' or divorced (write the word)..i i LE:�:. ��''bllate ofDeath.. 2/ 19.0
Age...4.4 Yeaj Months Days Birthplace.... C..`i�4rG J .4..•.." .j.l••
Cause of-Death % •••
Certificate was signed by C ,sy �� ��� .D.
Address ;.4!i .. ... C e e4A_ . ' r
Place of Burial (or Removal) � !` ,- �l� t
(If body is to be temporarily held, fill in spacg ate,. i
Cemetery . 1„!�� , Date of Buda'... ....�-�. f 19
(If body is to be temporarily held, fill in space later
The Certificate of Death containing the above(s ted 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
Numb f'r,`and on jte..basi , thereo I HEREBY GRANT A PERMIT,
• ( dress)
1
the to hold temporarily and • - . - the body'
(Unire aker or person having charge of corpse) Inter, ,or gibe ise dispose of [state how])
Dated 1.,-..t.::,- 19..; ../ (Signed). �� cal R istrar
This Permit is sufficient for the Removal (and Interment or Cremate n) of ody 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 CARE MADE
Date of — was 19_
(Intermet!( or PM((ONO
f /j/
(Name of Cemetery, Crematorium, etc.) j
Section / Lqt No. - Grave No._.__1
(Signed)
eft°^ 111 Fikic#Sa
Address -�,..._
Person in charge must return this Permit to the Regist
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.