Austin, Eva NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q4F 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, V. egistered No.--
Dist. No: +;5. Co t"-- r 1
Name of deceased .._ ..�� (If city, give street address)
-04-4i.'"--/ ,. Veteran
r`t�/ (If v teran, give name of War)
Single, married, widowed, \t)
Sex. or divorced (write the word) iDate of Death / ! 1 V lk:?.7
Age... _...D....-..-_ ,it ,rs....t 11- o the Days Birthplace
Cause of Death. ' ,'
� �►Certificate was signed by... ,1,a, it �I4.1
M.D.
Address � - ��II .
..._ .._
Place of Bur. I (or Re oval)...Jr S. ,-
(If body is to tem Wily hed, 1 in s :c later ) / �`
Cemetery. - s- r..0 — ' Date of Burial ( 1.... /7 19Y'.
(If body is to a emporarily held, fill In space later)
The Certificate of Death containing the above stated particulars, having been presented t me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY A --REQUIRED BY LAW,
I have accepte the same for registration, have recorded it in my Local Rec rd with t e abov ' ` ted RePrige ed
Nu and o s' ereof I HEREBY GRANT A PERMIT fz..Q(a
�
the to hold tempora lid :�, th dy
(U rtarersn
r or po having charge of c pse) (Inter,r ove, oth ise ire of [state how])
Dated ... 19 ... (Signed) .�{..a ..
� Local Registrar
This Permit i sufficient for the Removal (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
f,
Date of /was 7:;'' / 7 19_ 7
(Interment or Crem tion)
(Name of Cemetery, rematorium,
Section____ Lot No. 5 G ( Grave No, "---
" � � .
(Signed) _ � (__� 6 cr
-'��--
(Person in Charge)
Address 7: - ( - . "
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.