Brown, Arthur 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village
Registered No. ',3 03
Dist. No..t - 0( County....� , -f--art-� or City .,f •-:c4: -/
(If city, give street address)
Name of deceased ,,L--c-- .. {- - - Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex /% or divorced (write the word) . , ` Date of Death ...� — ' `7" 19 ...
Age Years Months Days LJ Birthplace • y
Cause of Death ec _/.`.'-, (ee-G
Certificate was signed by 7 Aa.�-7 M.D.
Address '� ,... .� a ' --"
Place of Burial (or Removal) l -�� �a-� ®e
(If body is to be temporarily held, fill n space later).
Cemetery x--=u c- z:s. Date of Burial 7 - �-- 19 7.
(If body is to be temporarily held, ill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same appea '•g to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, haveforded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT _ �j
to - - �'A-�- 1 a :_e'.,r .j y
(Name (Address)
the to hold temporarily and `:- 4,.4.. the body
(Undertalper or pe, son having charge of corpse) (Inter, remg9e, or otherw a dispose of (state how))
Dated / 19 . .c...... (Signed) .5'3'a,/ /� y/
Local
This Pet it is sufficient for the Removal (and Interment or Cremation)of a body to any part of the St to ( jec local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is req red.
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 oK -� y/�vas 19
(Interment or
t
(Name of Cemetery, Cry-ete.)-
Section Lot No. e Grave No.
(Signed)
(Person in Charge)
Address
•
Person in charge must return this P4mit o the R istrar
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.