Scofield, Rayden NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registere No. ,." X
Dist. No. 9,. Coun
Date of Death // — 09' 19
Name of deceased Ct. (If city, give,street a ress)
n
•• •
s (If veteran, give name of War)
Single, married, widowed, f. .
Vet 69'
Sex or divorced (write the word) LA,
Age i 7 Ye) „Mon s - s Birthp.lace
ause of Deat •----4.......la
Certificate was signed by.. .. .kse,.. . M.D.
Address '23 -I- ) 1::-A 6. I 4 8 4
Place of Buria or Removal)
(If body is to e te po;arily h I , fil in spac ter)
Cemetery :t.....-s4 Date of Burial \ ,...,"2_ 19
(If body is to he ter '
Fly he d,tiflirPspace ater
The CERTIFICATE OF DEATH containing the above stated rticulars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I - •ve accepted the same for registra-
tion, have recorded it in y ocal Record with the above stated Regist: -p mbe ,;and on t •• .1- thereof I HE BY A
PE T
Pr 1 .-----
tO Y ,' vi Aei
..„ 10-----
. s
dress)
ta..) k___
the to hold temporarily an ifi* the Dated body
(Un err or erson having charge of grzs.e) r, remove, or ot wi. e of (state h
gql 19 . Li (Signed) • • ... , .... .. . ..
, ocal Registrar.
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any t 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 OR
CREMATIONS ARE MADE
Date o 6 as /�19 ‘/9
(Interment of.-.Caemaciofl).- •
•
(Name of
Cemetery, , .}--�,
Section 2 Lot No. 0 Grave No.
(Signed)
(Person in Charge)
Address
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 District 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.