Monroe, Louise NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Igr 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.
Registered . SZ 57
Town, V11-1-a-gtr"
Dist. No. CO Nnty (..,4):12.),/.1.„ or-eitp- ,, ,.c_c_,,,,,..._ it....4..-,..."-um_.
Name of deceased
Veter(nlf city, give street address) •
,C)--"..----`1144-‘‘' Single, married, widowed,
or dvorced (write the word)i (If veteran give name of War)
Sex (A) keAir)ri)..Date of Death I. 1 •---- 19(..9.•
Age Years _Months Bi place
..,) 1 Qsz,z4-
ause of Deat Days .
V ' . _. ...... .S.......,. .. ...... -10‘
,-
Certificate was signed by .... . M.D.
Address
Place of Burial (or Re al , ft .
r—i-C14:2
19
(If body is reite_wrar 1 h fil.14ii. ce . ...
Cemetery Date of Burial fri.- .
(If body is to be temporarily eld, fil 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, e re ed it...„in my Lo 1 Record . h the above stated Registe d on the -. •do ereof I HE BY GRANT A
PERM -
\._ (
tO 0 sa/CPI -.)'/'-'-----
i\lame) ess)
the k---) to hold temporarily and 10 body
(Undertaker or person having charge of npp) I ter,Dated \ 19 (Signed) remove, or oche •IDd• 0 Of (state ho
- --•• — )
ocal ' •istrar
This Permit is sufficient for the Removal (and Interment or Cremation)Of a b dy to any of the St-ate (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS . 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 ' was 19
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
•
(Person in Charge)
Address
Person in charge must return this Permit to the Registr r
g g
of his District within SEVEN (1) 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.