Brewster, Stanley NEW YORK STATE DEPARTMEN I OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit car, be signed only by the Local Registrar (Derut: .,r 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. e to No.
Town, Village JS4 ''u P
Dist. No.. -6CPU_.(... County._.LOC or City
��� � (If city, give street address)
Name of deceasedICA44 1' T Veteran (}f��/) G/(�//
(If veteran give name of War)
Single, married, widowed,
Sex or divorced (write the word' Date of* -A&. (... .... 19._4 ?
Age Y Mont Days Birthplace : I? 17
Cause of-Death__. .. • .._.. --rel.r f"" e. . , _...
Certificate was signed byrK.CS ... I " M.D.
Address . u.s•�...t.....!...i._."
Place of Burial (or Removal) - z
(If body is to be m rarily held, fill in ie�te I� ( 7 7
Cemetery �� ate of Burial 19�p(
f,If body is to be emporariIy 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
NumMand on t bas• then f EREBY GRANT A PERMITQ›/ ....„4,1_,,i,t_ ii y
ti
ddress)
:(1:-/,—.0_ )
the '' to hold temporaril and the body
(u ertaker or person having charge of corpse) Inter,rem ,or othe ' e dispose of (state how])
Dated Cc� 19 7 (Signed) ..
Local Registrarar
Cer"."'—'
This Permit is 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 qn
CREMATIONS ARE MADE
Date --wa 19
lam,
(Interment
I Name
/ c Ce e ee ry, reniatorium, etc.)
L
3�... `(Pt No. ;'Zl C Or4Ve NO.-/-- —
(Signe „/_ �� 2,62
•
Ae4drpss ) i/ Lfife-t - ..
ar
Person in charge must return this Permit to the R ra
t'
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.