Arthur, Ruby NEW TORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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. ye'
Regis red,No.
/// i. , Town, Village 26..7 _..x.„„o
Dist. No j_(Q unty �`L�� or City
If city, give street address)
Name of deceased__..__.__ __ EtC Veteran _--
(If veteran, give name of War)
igle, married,widowed,
Segue. _ _ _ or divorced (write the word) Date f Death __ __ �� 19_.77
Age Years Months paysBirthplace /�
Cause of Death ��.,e..i: . :1- '-Z
Certificate was signed by .__ _ r.. _. _ • M.D.
Address � JZZ �'Place of Burial (or Rem val) __..i_,.g
2__ _ _.et.a(If body is to b tem orarily•h d, fill in sate / ✓
Cemetery____ t' Date of Burial _w /47( 19_.'77
(If body is to be temporarily held, fill in space late
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registration, have recorded ' 'in my Local Re rd with the above stated Registers umber„�tnd on the b sis thereof I HERE-
BY GR A PERMIT ) 7/`/����, �j�
to m �.� ' - J �✓/ " „ g,_."mil 4/Z it,../11
ame) f (Address)
the Z C � to hold temporarily and 'i1,� the body
(Unlerta for pe son having charge of corps ( t , remove, or otherwise dispose of (state how))
Dated �' � 19 (Signed) c(fg
i.o egis rar
This Permit is sufficient for the Removal (and Interment or Cremation) of ody 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
Date of `was <3 4-//9 / 7
(Interment or C4en)
(Name of Cemetery,
Section Lot No. Grave No.
(Signed) 4
(Person in Charge)
Address / ;26c—
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above Jaye.
If no person is in charge, the FUNERAL DIRECTOR.6r
UNDERTAKER MUST SIGN ABOVE STATEMEN
ri
write across the face of the Permit the words "No person fn
charge," and FILE PERMIT WITHIN THREE (3) DAYS
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDE*-
TAKERS violating the law relative to the return of perniits
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.