Smith, Josephine NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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, LEGIBL WRITTEN IN DURABLE BLACK INK.
Town, Villa Registered No. I.!
• ---,.7Dist. No 1 __ County- 4f ed4./ or-City e.e-�ri
(If city, give street ress)
Name of deceased Veteran
(If veteran, give name of War)
�?i /� Single, married, widowed,
Sex . . or divorced (write the word).LI�rG.P .....Date f eath._... 1i. . �... . 1 .
Age / jears. Months ays irthpl ee
•Cause of Death.(.. r C2AU .... .... t. 4.t r :. .. . :? . ✓
Certificate was signed by .. . ... . . .. M.D,
Address 2 - , .... :,,- .... ... ... (t73• J .L\S---
Place of Burial (or Removal).
(If body is to b emporari , II in space later) /
Cemetery..J :.1'l • ,. ... Date of Burial — 1 19- _
(If'body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated rticulars, having been presented 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 ecord with the a ove stated Registered
Number, nd g the VisAereof I HEREBY GRANT A PERMIT/ Q4
(N Address
the ,.. . _ to hold tempo ily and the ody
(ljltdertaker orr,rerson having charge of corpse) (Inter,re - erwise dispose o [ w]) I
Dated �� ?�/ — 19� (Signed)
ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b•- to any part of the State (s •ect to (cal
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) (3A2-333)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS CAR
CREMATIONS ARE MADE
k _ • - i tL/
Date of was 19
(Interment orb
‘77Z
(Name of emetery, Cne ee-)`
Section_ Lot No. Grave No.
610-1
(Signed)
(Person in Charge) /
Sfet—
Address r / ✓ '
Person in charge must return this Permit io the Re tray
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.