Ellsworth, Floyd NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
r.gr 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.
Dist. No.
Town,
-.-- '•1-7 County lil a-1 City
(If city, give str et address)
Name of deceased ...../ ...
,..,..47-z,
, eteran
(If veteran, give name of War)
S ..,, ,,,-..-t Single, married, widowed,
Sex ,,--
or divorced (write the word) Date of Death 1 /.7 19,/-7
Age .., 0" Years _Months vf.y: Birthplace
Cause of Death . e"..4,6-7/&..-11.. 6.1"--C-4...--e .,
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
1
(If body is to be?..smporarily <1
he , fill in sp e later) 0
Cemetery „(:...e...7212_, ..,<:(..,,ed..4.2
,
' - 7Aat/7 e of Burial ,r/t / 1976
(If body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above t ed ,articulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND-SAT F• TORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record wit the af o e aced Registered Number, and on the basis the f I HERE Y GRANT A
PERMET
to
the o ,old temporarily and - the body
(Un takes, .21.1c7navIng charge of c2sps , cInter, remove, or ot Ise dis ose of ate ow)
Dated 19 ..404. (Signed)`-f‘4:deZ.e.,e,.c,e_
al Registrar 7."
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject t ocal emetery 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) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
9-K 1'.;
,,e e
/7
Date of was �( 19 7�
� m(Interment or eaiien) (/
(Name o emetery, Cramiwreerienrrete .
J 4
Section `2 Lot No. /‘061 Grave No.
(Signed)c ,,44 ��
7---4,,,,...(..
(Person in Charge)
r
Address 44)4-?')C/ ,
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.