Branch, Bessie NEW TORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Imo' 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. ���
R gistered No.
Town, Villag
Dist. No...q C)1 County-- -. _. or City- _--_-._-_
If cit , give treet add ill
Name ofdeceased__ _ ___ __. Veteran
U (If veteran,give name of War)
Single, married,widowed,
Se or divorced (write the word __ Date of Dea 3—/i 19____„2...2
Age _ Yearsp Months ays Birthplace -
Cau of Zeath
Certificate was signed by M.D.
Address
Place of Burial or emoval) LiJ-r -. .(2- - 27 ,
(If body is to be to por ly held, f' in pace later)
'Cemete x __A Date of Burial --76f 19.. 2
(If body is to be tempora ily eld, I in space later)
The CERTIFICATE 0 EATH containing the above stated particulars, having been presented to me, after careful examination,
the sa - spearing to be COMPLETE, COR: CT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for r stra ion, have r rded it in my Local•ecord with the above stated gi tered Number, and on the basis thereof I HERE-
BY RA # PER T
t0 'l( Z/11'vl-C. �
(Name) (Address)
the .. . __ _ to hold temporarily and the body
(Unlertaker or person having charge of corpse) I ter, remov of 'se d -•os- • (s ate how))
Dated 2 f s 19_22 (Signed) ... , ... t'
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body 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) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
(:-;27<‘"S-11-
Date ofy was Li` � `L ��19 z 7
(Interment or Cremation)--.
7
(Name of rtg etgry,
Section Lot No. Grave No.
d`(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
UNDERTAKER 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 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.