Barney, Almira NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I1 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, Vi�ege Regis ed No.
1. /
Dist. No. Co t�111-p`�4.. -err-City- •
(If city, gives et address)
Name of deceased .. v"-'-^t.P,_ TD-e---- Ve ran
(If veteran, give name of War)
Single, married, widowed, /
SexV..e71A/%42,9t. or divorced (write the word) ate of Death 1�( 3 a 19
Age Ye s s Bi rt ce /�
Cause o eath0 �:-L.. ... .. Y.. _
e M.D. '?
1:;:ie‘
Certificate was signed by .... .,:.. .. esS-i
.... t`Address ......... .. ems...... '`�..:i I .�' .T L
Place of B ria (pr R Fval� - =�--�-. - �
(If body is t tempor it he d;fil s c `
Cemetery .. ...& _AD.-e t,? Date of Burial �„r 19b
(If body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after care ul 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 in my , o a 'e r with the above stated Registered Number, and on the ba ' thereof I EBY Gam/ T A
PERM+� "—
to • .yy _.e II �the to hold temporarily ruccra.ress,
. the body
(Unde r person having charge of c rp e) ter, remove, or ot}t'`rwt a isp se of (state how)
Dated ....... (Signed)
LocaI'Regi ar
This Permit is sufficient for the Removal (and Interment or Cremation of a body to any rt of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (V 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
7/ylo
Date of was 19
(Interment +er).
6 t
(Name of Cemetery, am:�.e
G
(
Section Lot No. /e/ Grave No. _
(Signed)
(Person in Charge)
Address /✓ '
Person in charge must return this Permit to th`e�; egistrar
of his District within SEVEN (7) DAYS from abovVdate. 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.