Bennett, Pearl 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.
["j � 1 Town, ago_ Regi t red No.
Dist. No. .... .... .. County.... ".-- .ot — ,....
A (If city, gives et address)
6
Name of deceased 'ea - (�ra fro
eran
(If veteran, give name of War)
Single, married, widowed, r , , 4
Sex or divorced (write the word) ...��L/•. . ..Date of Death _ PZ/ 196,7.
Age 91 a Years..1 =nths Day Birthp . Q
e
� -
Cause o Death • ... ......'...:.. ...,,,/'-
Certificate was signed by....) i--�--� M.D.
.. ...... ... .. ..
Address ....�-f _-� i - f - 9.11; '‘
Place of Burial 'eri(ov " '
(If body is to b:•or"krily(he�,fill in . e later)
Cemetery �._,4,�,�.j� 11.�,.C.�-te' Date of Burial -- ,,�-Y. 19C
(If body is to be temporarily held, fill 1n space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same Appearing to be C_OMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion have recorded it n c ecord with the above„,..s.„tated Registered Number and on basis thereof I HER BY GRANT A
PH:Wili
to 5�3 C. PIr�° L
Na '" adress
the .. .. ".. to hold temporarily and • y^� the body
( ndertaker or person having charge ofcr,pse) n , move, or oth� ✓dis sie.of (state how))
Dated — a19 . (Signed) . . .. • ••• ... . .........
ocal Registra
This Permit is sufficient for the Removal (an Interment or Cremation)of a body to any p t of the State (subject to local cemetery r
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 >447 19-49.7
(Interment Cj: 1)
(Name of Cemetery, CrC': Pte.)
Section 7 Lot No. Grave No.
•
(Signed)
(Person in Charge)
Address
r .
Person in charge must return this Permit to a 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.