VanHeusen, Lewis NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qgr 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.
Town, Vi-1age_0 Regis d No.
Dist. No. .c. c.-- ..... ounty .. .. . oret-ty • '
(If city, give street a,.ress)
Name of deceased 101-��. --e-«- Vet ran
(If veteran, give name of War)
Single, married, widowed, /'
Sex ... .... or divorced (write the word) 2il c< ate of Death\:1 I 19 .(�
Age 2,........Yea c .Months Days Birthplace
Cause of Death
Certificate was sign d by . M.D.
Address .. CIL �<''��
Place of urial (o emoval�
(If body is o b o arily held, car
spa ;later)
Cemetery . .... Date of Burial ...
(If body is to be tem or rily held, fill in space ater) 19�,/,
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, have accepted the same for registra-
tion, e re rded it in my ocal Recor with the above stated Registered ber, on t basis t o I HERE Y GRA
FERMI - j
to llk.
e}-- aare s
the ............. ... to hold temporarily and the body
(U ert or per on having charge of rp ) � r, remove, or othe di.,tre of (state how /
Dated ,�........ 19 .�...... (Signed) or <
A ocal Registrar
This Permit is sufficient for the Removal (an Interment or Cremation)of a ay to any ,TI t of the State (subject to local cem=tery 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) 13A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date oAa;;;e4Plij was >7 �"r 19 �7
(Interment or G-- ) /
T.72%,
(Name of Cemetery, Gameregarin
Section Lot No. Grave No.
�✓/ '(Signe
(Person in Charge)
Address, �� ���i�! .
Person in charge must return this Permit to Zegistrar
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.