Eddy, Dewey NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.
Town, Villag
Registers No
)ist. No_ /°i County or City `�' ��=�- `a' 2
(1 ty, give street address)
;ame of deceased �' Veteran
i Of veteran, give name of War)
�G� Si gle, married, widowed, 9 e4., rn�k,�r ' � 2 , 3 0 C``
iex or divorced (write the word) Date of Death 19
kge `7/ Years. Months Dvs Birthplace V
�ause of-Death CPS�eLo-le-a1.G aec.: 44��
certificate was signed by A • 2.7744, M.D,
Address G4 vytie. C ,/3-a :, .
'lace of Burial (or Removal) . eQ '
If body is to be toyvg�r tr�Iy held, fill in sy a�e�--Ittsr) 2- Y
:emetery (.! .Q,. (�.lr Date of Burial �J'"r 19 67
If body is to he temporarily held, fill In space later)
[he Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
lation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
[ have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
m"b2'2-1
and oche b tl ram- I`I�EREB-GR3ANrA RMIT a � cn,PCs-Ctu�.� 7` 1 , '
he i`73'4c-e- 2"
Nam4-16 to hold temporarily and ��-t6e-r...-- the body
(Undertaker or person hay g charge of corps q (inter re �e,_or of a disp stat�'towl)
)ated '7'7 c�-e7". / 19 C/ (Signed)..a e--:z:k%z'Sx— s 1- n
Local Registrar Ty/. . ,
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
:emetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 62) is required.
rorm 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` L was. Z r,'---�j ' 19"" f
(Interment elf-GpaautinnL
1
vL1
O
Section_ 7 . _Lot No. ,g77. Grave No._
(Signed) .... 4>--Pe--
(Person in Charge)
Address g r==
,1/4,...e,, ,
i
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.