Van Clette, Addison NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
2:_ ;' 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 COMPIrETE CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, V. gistered No.
Dist. No 6 ?CounL1\ -9`1"-\,. or-City .. --lee--
(if city, give street address)
Name of deceased (...).Ofr""1- . . Veteran =—ems
(if veteran, give name of War)
Single, married, widowed, �?
Sex or divorced (write the word) .r.-!. Date of th.....f . ?0 l ,l
Age .Year: ._.._,ii...g Mont Days Bir lace � 1 u't"'
Cause o 'Dath...._._ 1. ;• !IA ; a . _... s'_...._ , _ 'V 'k'c',.,,no.
Certificate was si ned e, „1 .�V .� M.D.
Address..-�r ii .. �p% . .0.. .
Place of Burial e r R; •v. . " ��
(if body is to be to 7.riil held, sp date' ` �f
Cemetery s t .�, .Date of Burial `/ 1q
(If body is to be temportrily hel., fill ',space later)
The Certificate of Death con .ining the above stated particulars, having been presented to me, after careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I h. • acre e t-d the same for registrat. n, have recorded it in my Local Recordwit he above stated Registered
Nu a r, al`n tfie b is thereof I REBY GRANT A PE MIT
the to hold temporar' d the dy
(Un ertaker or perso havin charge of Coe
8 8 /1 (Inter,remove, erwis is e of [state how))
Dated ..- 19 , (Signed) 4 -- . .-•---•
al Registrar
This Permit is sufficient for the Removal (and Interment or Cre ation) of aody to any part of the State (subject t local
cemetery or other regulations), unless removal is by common carri • 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 qR
CREMATIONS ARE MADE
Date of . 1n t'i'L, was J)4-���{ S 19 Qi
(Interment or: 1)� !I I
,�t.i 1Y iCV.C4) Yrl 2. 4
(Name of metery,-tilawaluei_,t., . ...)
Section_— 2,C i.,.. 1_ Lot No. / Grave No. `
(Signed) --_
(B rson in Charge)
Address 3 J q/c A40 ✓„.,v, /V
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 Dis-
trict 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.