Fuss, Fred NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tAr 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 CERI�IFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. �.'✓�_)
Town, Villa
gist d N
Dist. No. S‘G untG or City
(If city give street aJs)
Name of deceased !/�i2 G 1 � Veteran — eva./.- L--
/ ���� G
(If veteran, give name of War)
Single, married, widowed, d
Sex . ,., or divorced (write the word) .. .s / Date of Dea ..... ".. 2 19 .76..
Age Gars. Mon s Days _ Birthplace
Cause of Death
Certificate was signedb�j.. ../�.. M.D.
Address rJ (/'... ......... "; `,� Ly
Place of Burial lagemoval � ......
(If body is to be .•rarity h , (ill-in sp a late
Cemetery i/ Date of Burial 3 - f 1976
(If body is to he tempo"orarily hel , fill 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 QUIRED BY LAW, I have accepted the same for registra-
tion, recorded it in Local Record wi the above stated Regist r d Number, don the basi thereof I HEREBY GRANT A
PER 7 ...
(Name) ( ,(Ka- ress
the . to hold temporarily and the body
(Undertaker orpqrson having
ing charge of S.,or .se) er, remove or oth tse disppo of ( tate how))
Dated /G (Signed) .. ..( !�,{�1 s!!2j/ , e..r..........
Local egigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of 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
Date ob was >74 "Jig 7
(Interment or Cteereatie. _._.
I
(Name of Cemetery, ma e�
i4"-4,17
Section Lot No. /DJ7Grave No.
2-7, `' ���� "`�v
(Signed)
(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 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.