Nailae, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ate" 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 COMPLETECETIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village
Registered>�d/Dist. No. � ,r� ounty/e4r,:�G.e-,.cr� or City -�
(If city, give street address)
Name of deceased � � Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex �-� or divorced (write the word) Date of Death 0-4' 19
Age a.?----- Years Months Days Birth ce '1,
Cause of Death e t-<.A..- �`" �.f -
Certificate was signed by ;2 O :.�c..,' M.D.
Address .� s....— CLr .,
Place of Burial (or Removal) b 6
(If body is to be temporarily held, fil in ce I r) y�
Cemetery Date of Burial t7 3(-) 19 6e7'
(If body is to he temporarily h , fill in ce 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 Re�ord wit the above stated Registered Numbe and on the ba 's thereof I HEREBY GRANT A
PERMIT
to - y� j . .
(N e) - (Address)
the ;.7t4 ;c-- to hold temporarily and the body
(Undertaker or poop having charge of corpse) (I to rettry6v , or h (state how))
Dated 27 19 .1P.? (Signed) GWL
Loca R stra /
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to an art of the State(suto local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit Po. 62rs 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 (s)-nt2iiili^At was (,lt cry. 0 19 (p
(Interment e4,-- +aerietr) o
i
(Name of Cem ter €r a
Section Lot No. 1).)4-4 Grave No.
(Signed)
( erson in Charge)
Address 3 id /UQ4 0- Q /t
•
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.