Haviland, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gam' 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. r_�
Dist. No. `SC°/ County //,, JJ
or City
Town, Village Reg: -""No. �o`.
W.... .... ... 1��� ...
(If city, give street address)
Name of deceased 4C-CA-d--dt--7`21',...724, p7teran " i
)717
Single, married, widowed, (If veteran, give name of War)
Se .4 or divorced (write the word) Date of Deay / ‘ 19 ..7�
Age s, Y r Months Days Birthplace ,....r•
Cause of D thlif
Certificate was signed by M.D.
Address �f(� l� �:
Place of Burial r Remova -r--r -4i )(-7(If body is to be porarily he d," 11 n pace
Cemetery ...,C/YLE�, ... . . . Date of Burial �� 19 IC
•,.
(If body is to b temporarily held, fill in space ater)
The CERTIFICATE OF DEATH contai ing the above stated particulars, having been presented to me, after reful examination, the
same appearing to be COMPLETE, CORRECT, AN SATISFACTORY AS REQUIRED BY LAW, I ha a accepted the same for registra-
tion, have corded it in Local Record with t above stated Registered Number, and on the b 's the of 1 HEREBY GRANT A
PERMIT ) ``
Name)to
( caress)
l the the (Und to or person av c arge of corpse) (Inter, re e, body
to holdtemporarilyan ' . •
••.. � •� or rw �isp•-e of (state how))
Dated 19/b (Signed) >t
• oca 'egistrar"
This Permit is fficient or the Removal (and Interment or Cremation)of a body to any p rt of the State (subject to local cemetery or
other regulations) nfess removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
NORM VS. 61. (Itb:V, 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date ircy226was � l u19 ��
(Interment or Cr!hcatr'trtt}-.
(Name of Cemetery, Cretwor,um_, elc-a,
Section _--1-- Lot No. t5-1 Grave No.
(Sig¢ed5
�� (Person in Charge)
Address—
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 acro e
face of the Permit the words "No person in charge, d
FILE PERMIT WITHIN THREE (3) DAYS with the Regis
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAK
violating the law relative to the return of permits are liab
a penalty of NOT LESS THAN FIVE DOLLARS NOR MO
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. Th
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.