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Shaver, Minnie NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT itS5P 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 CERTI- FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered o. / iker Town, Village Dist. No. 6County or City If city, give street address) Name of deceased /Ux�Yt.c e / .e,--e. --1 Veteran (If veteran, give name of War) Single,married,widowed, / ' -----pl-- -- -- - or divorced (write the word) __. Date f Death ---6 ...7 19.7-/ Mont s - a BI hce Age Year -_ • Ys P Cause of Death • - ,�,( / • • Certificate was signed by _-- _ - -- 27-,-(- -.,- y � �77(---ei. M.D. Address Place of Burial (or Removal (If body is to be temporarily eld, i pace 1 e �~ � 'Cemetery (,�_- / Date of Burial 1 i 19__._ (If body is to be temporarily held, fill in space later) ` � -�. The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after reful examination, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for reg. ation, have recorde it in my Local ecord with the above stated Registered Num r, and on the thereof I HERE- BY G A PERMIT!4� ale to l4 4 u't - ale 76A� the �� (Na e) � (Address) f, to hold temporarily and ___ the body (Unlertaker o person having charge of corpse (Inter, r ve, or otherwise dispose of (state how)) Dated /D 19- 7 (Signed) i This Permit is icient for the Removal (and Interment or Cremation) of a bod to any part of the State (subject to local cemetery or other r ulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required. FORM VS. 61. (REV. 6/63) (6A2.130) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of was (I // 19 77 (Interment or Cremation) (Name of Cemetery, Olverf a or um, ^Section Lot No. Grave No. .6.—PL (Signed) �` `�"+ (Person in Charge) r Address / ���-('_ lee a 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 UNDERTAKER MUST SIG] ABOVE STATEMENT, write across the face of the Permit the words "No person"4447 charge," and FILE PERMIT WITHIN THREE (3) DAY with the Registrar of District i which cemetery is located. SEXTONS, FUNERAL DIRECTORS and UNDER TAKERS violating the law relative to the return of permits, are liable to a penalty of NOT LESS THAN FIVE DOL LARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The law will be enforced. Local Regis- trars are required, under penalty, to report violations thereof.