Paul, Walter NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itgF 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 COMPL TE CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. f /t
Town, g
gistered No.
Dist. No:"`', County . D ... ,er City
,n, l, (If city, give street add
Name of deceased �..1t/ Veteran
If eran, give name of War)
Single, married, widowed, - /'C
Sex.\qj&. . or divorced (write the word) Date of Death / J 19Ageears..... Months................ . a Birthplace.Cause
Certificate was s,ig, }ed b .... .. _ _ . ... ... .. "`'"`a'G NIA
Address "a./.. I -4j f
Place of Bur' r Removal ..._ _ __ .
(If body is to e tempo Mrheld, fill sp co later .r-
Cemetery Date of Burial 19
Of body is to t por'tr� ily held, in space later) I
The Certi 'ate 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 hav accepted the sa e r registration, have recorded it in my Local Record ith tt 3J V ''ve stated egistered
N ber, and on th basi t eof I HEREBY GRANT A PE I I'/
to_ w..
the to hold temp ' y and he body
(Un rt er or er on having charge of s (Inter,re ve,, Qt er dispose of [stat
Dated 19c .. (Signed).. ._..
/ Local Registrar
This Pe is sufficient for the Rem al (and Interment or Cremation) of a dy to any part of the State (subject to local
cemetery or er regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 82) 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 4:- �"'�%%"Zilwas *4'76."-----
19 ‘/
(Interment ortiiaenntio+r}
/ t
(Name of Cemetery,
Section Lot No. / (` Grave No._:-2__
'
(Signed) �/
(Person in Charge)
Address '
1,0„2471., jiC. GfJ ,
erson in charge must return this Permi o 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.