Arzberger, Kirk 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. 1/�e,, -Rel S
VI .if�1 Town, Village 'ems . ....
Dist. No.0 1O /V �'County... or City
(If city, give street addres
Name of deceased '�� f..A-�J .... J - Veteran
(If veteran, give name of War)
� Single, married, wi owed,
Sex RUCnn - - or divorced(write the word) � Date of Death 04-1.........19 .76 .
Age li Years.. onths , Days Birthplace
Cause of Death ..
Certificate was signed b ............... ... ... .... • , . M.D.
..
Address j. ... ........... 4-7L.G. .,
Place of Bur' 1 (or Removal)
(If body Cemetery is .. ratylyJheld, (iII i ace at c
ry (f (((/// Date of Burial y 1976 •
(If body as to he temporarily a fill in space later)
The CERTIFICATE OF DEATH containing the abo a stated particulars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, D SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav ecorded it in y Local Record wi h the above stated Registered Number, and on the b s they f I HEREBY GRANT A
PERMIT ����� /I 3 C /- 1. �� _ Qom_
to Name) / (C� Al:ress) s �`�' /
the (-(--"?` to hold temporarily and 4-I--44--' - the body
(Unde aker or pe on having charge19 corpse) er, remove, or otherwise dispose of (state how))
Dated 0 ,..3 7 (Signed) { -N.
This Permit is sufficient for the Removal (and Interment or Cremation)of a body o any part of the State`(Oi• bject 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. (ItRV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was
(Interment or
(Name of Cemetery, )
Section Lot No. /d Grave No.
(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.