Viger, Edgar NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qom' 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. LI
5 Town, Village Regist d No.
Dist. No. ..S . . o ty L'Oet.AA.9-4./\. Dr C.i•ty-
(If city, give street a ress)
Name of deceased � {�!� Vet ran
(If a ran, g e name of WA!)
Single, married, widowed, \
Sex or divorced (write the word) .Date of Death IS 196?
(Age ... ars Mo t D Bp4place %...........
Cause of Death „,c4—G ... R .ram tl
Certificate was signed b \--... M.D.
Address ... ........ It- —�
Place of B 'al ( v a 2 A.,..,;,.�, 0
(If body is t mp r h , f" in space la
Cemetery . ... ........ Date of Burial ( 6 19 69
(If body 1s o` a to poraril a d, it in space ater
The CERTIFICATE OF DEA H containing the above stated particular having been presented to me, after car 1 examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra•
Lion, have.recorded it in my L� 1 Record, ,[h we sed Registered Number, and o ba 's thereo HER Y GRAN A
F M PI ) C // `�(Cjr
me) dre
the _lv.. a' ��, to hold temporarily Vir
�-� the b dy
(Unde�,t�ker or perso having charge of cor se) ter, remove, or oth wtust di of (state how))
Dated 'r`�( _,,....(....t 19 (Signed) .
°cal egistrar
This Permit is sufficient for the Removal (an Interment or Cremation)of a body to any p of the State (subject 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) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 2was /6 19 et
(Interment or Cremation)
(Name of Ce etery, Crematorium, etc.)
Section .210• -0 Lot No.2. VFt- Grave No.
757
(Signed)
Person in Charge)
Ad dress X2e4.4 " � Q
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.