Ryther, Addie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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.
I Registered No. 7
_ //� Town, Village
Dist. No. .' '6 ,/ County .1 / r.:;,Z„/ or-pity [ .,d. Z.-.. ,:I ea.,,t��.
/ ,,(„ (If city, giv street address)
Name of deceased - ' G:.0 '...r.7tri / Veteran
Single, maFIled, W1flOWey, � (If veteran, give name of War)
Sex Csz ;•l - or divorced (write the word) GCy �� Date of Death -' . q.. J9 (p
Age ..Q Yea . .Months Days Birthplace...:, �" .,�!C �
�-
•
Cause of Death .... . .. . rGG�i.. 4C-. ' " - ..�7.a:L�
Certificate was signed byj__ // -7 .. �i . 6 7/ M.D.
Address .. Ir ,/"".. .:
Place "4"---4---
of Burial (or Removal)
(If body is todbe)temporarily,h ld, c rated J
Cemetery ../.. .-..,....... .-C Date of Burial :; CSC .l�,c 19 �F
(If body is to he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to the, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra•
tion, ha,ve recorded it in m Loca Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERM; �� _��� / f,, � /
' fr
IO
kweerarl:Y . 7/7'
o} p (Na e) (Aax so -
the to hold temporarily and tj-e body
(Undertaker o erson having charge of or se) +. Inter, remove, or er dispose of (state h ))
Dated p . 19 �7, . ..... .. .. ... ...(Signed) ...a.:... . ... . .... r...:..
i , ocal- egistrar
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 OR
CREMATIONS ARE MADE
Date of was "-1- CI 19
(Interment
(Name of Cemetery, C
Lot
)1V-'.11--eM-It-A--
Section L No. \9/ Grave No.
(Signed) —
(Person in Charge)
Address ^'
tson in c arge must return Permit to e 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.