Johnson, Ethel NEW YORK STATE DEPARTMENT OF HEALTH 7
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ea" This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town.
Vilrage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURAB BLACK INK.
Regi tered No. . ...
,+� Town, Village }
Dist. No.... L' .... County /4---
� �� or City �(!f city, gi stre t adQress)
Name of deceased. .k' eteran
(If veteran, a name of War)
Single married, wi ed j�
Sex or divorced(wrte the word) �7� te of Death �7. ( 19 .7
Age 7 Years Months Days Birthplace /''
Cause of Death ......et_...r jr'�=T / �
Certificate was signed by : /� M.D.
Address
Place of Burial • 'Removal
(If body is to b= srporarily he , Apace ate.Cemetery Date of Burial y 2- 1917A
(If body is to b tern y held, fill in space later)
The CERTIFICA OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same appearing be COMPLET , CORRECT, AND SATISFACTORY AS REQUIR D BY LAW, I have acce ted e same for registra-
tion, have rec• • : it in my Lo ec rd with the above stated Registered ber, an on the basis the H R Y GRANT A
PERMIT
to G ` L /J )v `.. 7
,1 iS
the to hold temporarily and k� the body
(Unde a er or person havipg, arge of corp,se) Inte , r or other s spose o state how))
Dated y.. k..'..19 .7 (Signed) - t,,.,/
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)o - .ody to any part of the State(subject to local 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) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
,a-z----,,,r,„,,,e, „b, ,,,, „
Date of was
(Interment or Cremation)
1:1-T ' I/
(Name of Cemetery, GrernoFteti
10-ta---t ,--_,(4:041 at-fr- . ,..„ _____
Section &,1 Lot No. N2-v ad Grave No. `-5
(Signe - " �� y ^'
/- (Peerson in Charge)
-ei4eAddress fib
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 pelrson 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 OLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof. '