Balfour, Baby Boy NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t:'• 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, Villa t registered No.
Dist. No. ��Z0 / County or City. �x � /��ee-
(If city, give streetaftTdress)
Name of deceasedVeteran
.re- ( veteran, give name of War)
Single, married, widowed,
Sex , -4 or divorced (write the word)! Date of Deat • 7 19 /
Age • Years Months Days Birth 1 ce
Cause of Death te -- l -e ., .-2xQ ,,,e, /e'e- ye -
Certificate was signed by J M.D.
Address •c, �—
Place of Burial (or Removal) -'7C- �-u- � M
(If body is to be orarily held, fill in i,ace ater)
Cemetery • p �� Date of Burial 19
(If body is to be temporarily he , fill in space
The CERTIFICATE OF DEATH containing the above stated particulars, 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, ha :corded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMI
, ame) •
�ddress t
the ......_ to hold temporarily and the body
(Under aker r person having charge of corpse) (Inter move, or other e dispose of (state how))
Dated .. 19 (�f (Signed) r� �y.. (�
Lo 1 R�gilt/14
This P' mit is sufficient for the Removal (and Interment or Cremation)of a body to any part of a State (s "ect to ocal cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is require
FORM VS. 61. (REV. 6/63) 13A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of /"( l r was 19
(Interment or-Ccemetity1)
s._ < (Name
x /ram t.1/
..
of Cemetery, Cremit'otiuin,-etc.)
Section i' ' Lot No. Grave No.
(Signed) k ( t /7, 5
(Person in Charge)
Address
Z ; )-
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 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.