Baker, George NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Zer 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. �l/�
Town, Villdsc egistered No.
Dist. No. C t — ul Y:\-
(If city, give street a dress)
Name of deceased _ ,. Veteran
Q0 I (If veteran, give name of War)
Single, arried, widowed, c
Sex-
or divorced (write the word) .. . - ---.Date of Death.. .......B 1 . 7
Age 1 ✓'ra. No Days Bir lac }
Cause of-Deat ✓W ��^- `�.
Certificate was by ... M.D.
Address_ •. . ,._ -,•-,..
Place of B 'al (or a 1) ... .. ...
(If body is to , to I.or rily 1 i spat later) `
Cemetery...s.. 'y..._.. ,.. .. Date of Burial ` 3 19Ci.�.
(If body is to , emportrily held, 8 In space later)
The Certificate of Death ntaining 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 h.,,• a • ,ted the same for -g. ation, have recorded it in my Local Record ith t e states 'egistered
Numbe , f . . asis the��f I. EREBY GRANT A P RMI - ��
to._ . .. - .. 1.
sme) s)
the . . .. to hold temporarily t dy
(lln ertaker or person having charge of corpse) (Inter,remove,or 4 • pos [state how])
Dated '^ . --z �� 19-- (Signed) 4. _., .. .-.
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body I 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, lit) 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 of was /0 19 -Q.
(Interment a C�wetisn)�� /
I `�•Fv
.11Y1
Name of Cemete Gwnwiw:_..., _t_.}
Section S. Lot No. f ViNGrave No.____
(Signed) _ l
(Person in Charge)
Address 3 3 a't'z ,& i 6), F
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.