Dunkley, Rose NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qom" 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. g
Town, Village �' Registered No.
Dist. No. .�.c -7 County ... .e.-. � or City
(If ci[y ive street address)
•
Name of deceased �0-- , Veteran
(If veteran, give name of War)
j Single, married, wi owed, -�
Sex ..(,. ij?-L.:� or divorced (write the word)�/ i�4 4 t'' Date of Dea 7 Ja 19 SP...�...
ge.... :,e� Years .Months Days Birthplace * / �� ,l. fr -J7
• ause of Death 9-. . .. - a.- t .1- .. , �G� fre:.'
Certificate was signeay • / , M.D.
Address ....l.cP ..Gl.t.._.a: . I ,S du�f 17. .
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Place of Burial ( r Remo al) '
(If body is tob tjm
nporarjly held, fi 1 in spa a ter)
Cemetery Date of Burial / (- 1 1-4-- 19 q
(If body is to a temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated pa 'culars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it.' my�ocal Record with the above stated Registered N �ber, and on t basis thereof I HEREBY GRANT A
to
ERDIIT '� � �- �1�,.��C'
/ ame) dre ),'
the • to hold temporarily and �, the body
(Undertaker or perss�on having charge o co e) ,%',� _ (Inter, remove, r t r se dispose of (sta `h w)
Dated l /- / C� — 19 67 (Signed)c'/... .L.d t .. ..
o Registrar i ;
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any,kart of the State (subject to focal cemeter or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/631 (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
)
Date of was 19 ‘-‘:?
(Interment ozac;vr>?—
•
•
(Name of Cemetery, Grematoriumrete:)-
Section / 7 Lot No. 0"A Grave No.
(Signesl1 (,
1 r/
(Person in Charge)
Address F/
Person-in charge must return this Permit to the Registrar
of his District within SEVEN (1) 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.