Forsyth, George NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar 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 CEJtTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /`
,r J /Q� Town, Village Registered No.
Dist. No. tv/ ounty w or City
✓ (If city, give street address)
Name of deceased .. ' ... eteran
(If veteran, give name of War)
Single, married, wido d,
Sex < e .r or divorced (write the word) .. Date of Death -3/l Y ,19
Age r.?h Years.e Months Birthplace T'7 ` ., -X./�_
Cause of Death s.,
Certificate was signed by n . ... M.D.
Address . }� C!
...24k
Place of Bud (or Removal �JZcl '
(If body is to i emporari4y he 11 lin space later
Cemetery .�/���/..!�- rr1iL f� Cam— Date of Burial 3/77 19 7 ,
(I( body is he temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particul , having been presented to me, after careful examination,the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY S REQUIRED BY LAW, I have accepted the same for registra-
tion, have reed it in my Lo! c 1 Record with the ove stated istered umber, and on the basis thereofHEREBY GRANT A
PERMIT 4/`/
to `re417--(daress).
/C
e) '
the ... -e e 7 to hold temporarily and y
. ... Y.,'
' the body
ndertaker or erson having charge of corpse) (Inter, remove, or otherwise dispose (state how))
Dated
.. ...4`� 19 ....;7..� (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any p t of t e State b )Ii ocal 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
? iK
Date o }� ce was /7, /7 19,2‘
(Interment or .r..R.nirtio.;—
(Name of Cemetery, Crenrarofium, etc.)
n
Section Lot No. ts3;b6 Grave No.
(Signed) 7Z• tr f lir)ei,e"
(Person in Charge)
Address X ,'
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.