Riley, James NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No.
Town,
Dist. No.NgeSy... Co nty_ar. or City .i<L,,2.. G �
• (If city, give street ress)
47
Name of deceased (i/ ' Veteran
If veteran, give name of War)
D Single, married, widowed,
Sex `r4.- or divorced (write the word).k a.. ....Date 2. eath - . . 19.4?.
Age 70 rts,....e.. Month Birthplace.../4 ... . ...
Cause of-Death.. . . ._
Certificate was signed b .... ,.... M.D.
. ..
-:-.. • ---) -y---
Address /�„.. '
Place of Burial or Removal).. , .
(If body is to bet 'p rarilji held, fill-in space later)
Cemetery Date of Burial .<'`i �1.Zr'41 19
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated par 'culars, having been pr•-•rated to me, after careful exa i-
nation,.the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Rec;rd with the ab a stated Registered
Numb ti ba4sisj thereof HEREBY GRANT A PERM /,„,,,
�y/J�i -�i+, �'1i
4*,
the, to hold tempor rily and L.. rL/ body
(Undertakes or person having charge of corps (Inters re ovi. the ise dispose of [state o
Dated / " /0 " 191a (Signed)._... .. 1A.ic..G.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a boo., to any part of the State (subje to to 1
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 qR
CREMATIONS ARE MADE
Date of - �c-u-?.,- as , �'i `�/ 719 /
(Interment of y'
7::, --t---71—e_,
(Name of Cemetery, CremaW -ete.)
1i/1i lai
Section_ 7 Lot No. `-----?7-
-----?7 Grave No._____
' '-----Q/'
(1/th--ilvy ,/
(Signed) <... L 'L
(Person in Charge)
Address -" ✓J �
, .. �-� ?
Person in charge must return this Permit to, he 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.