McKinney, Earl NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
DSF 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 COMP ETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
(7 L
Regist ed o.
1(}tiAz4,1} Town, Village
Dist. No. J` d 1 unty or City )��' %
y If city, give street address)
Name of deceased __ 2)77? C/ Veteran
(If veteran,give name of War)
Single,married,widowed,
Sex &- - or divorced (write the word) Date of Death _._b.,9 1- 19.77
Age Years opths Da s Birt}pla _
Cause of Death ��L �J
Certificate was signed by M.D.
Address > it- e •
Place of Buri (or Removal)
(If body is to be a oraril eld fill ace ater) 7
Cemetery--- Date of Burial /l 19--/.)
(If body is to be temporarily held, 11 in space later)
The CERTIFICATE OF DEA containing the above stated particulars, having been presented to me, aftetlareful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I ave accepted the same
for re istration, have recorded it in my Local Record with he above stated Regist ed Number and on t f- basis thereof I HERE-
BYtOG NT P RMIT 6ft/ // g
(Na e) _ (Address
the /A__ to hold temporarily and _ the body
(Unlertaker person having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated 1 19-7? (Signed)
Loc
This Permit is su cient for the Removal (and Interment or Cremation o 'a part o e State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which cas 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 ofr was 197
�i (Interment or Crematioi
XJ t s�f aLt ciJ
(Name of Cemetery, Crematorium, etc.)
Section C Lot No. Grave No.
(Signed)
( erson 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 of
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.