Shepard, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
12r. 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, Villagestered No. ... `3
Dist. No. - .1) / unty ..G .P�4/ or City - e.�..--/
(If city, give street address)
Name of deceased .V": Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) ,i -4-e-{r' Date of Death / -f 19 9,
Age f . Years Months Days Birthplace
Cause o Death ..0 /'� ,G�i...,�.� ,¢..tom-,--, '` .. .,
Certificate was signed by .--e -mac 2' -��cr // M.D.
Address
�5 �
Place of Burial (or Removal) � �.����
i �(If body is to he temporaAri�l• he d, (t in ce late
Cemetery dam ov-7C.,.e.-c.,.- Date of Burial .../ — 77 19 G�'
(If body is to be temporarily held, in space later)
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, have recorded it in my Local Record with the above
� stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMITtoQC / ��c``. -'`� /p L r`-abo - ,,.. ..�.. , , 7
(Name) ' r (Address
the to hold temporarily and the body
(Underta'e or person having charge of corpse) (Inter, nove, or other' dispose of (state how))
�
Dated ...., - 19 ...dF, '(Signed) DJLoc Registrar
This Permit is sufficient for the Removal ( nd Interment or Cremation)of a body to any partState (sub ct to local cemetery or
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) 13A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was �''` a✓� Li 19
(Interment atR 1*)
+r
(Name of Ceetery, €et mn;--ert.)-,1
n(
Section j_- k b-fir,` Lot No. I�(- Grave No.
(Signed) � ...,....' sC_- �y
(Person in Charge)
Address t7 74 / / ;41,, d/rc tY: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 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.