Doray, Mae NEW TORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
E 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. 0/Register d No.
Zij
• Town, Village
Dist. No. `5� �/ County or City
If city, give street address)
Name of deceased 7-17 /f Veteran --
(If veter n, give name of War)
Single, married,wido d,
Sex _ or divorced (write the word Nr Date of Death _-_ __.. _._ 19.._I--7
g ys .
Age ____ Years Months _ _ i a BIrt lace 2L�Z t�fr
Cause of ath
Certificate was signed by r M.D.
Address L
Place of Burial (or Removal) _ _ _.,C.C_R.R s....
(If body is to be a poraril el fill ace later)
Cemetery__.c .,______ _ -_ __ _ __ _ -- Date of Burial__ ,---C 19.17
(If body is to be temporarily held, ill in space later)
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 acc pted the same
for re i ration, have reco ded it in my Local Re o with the above stated Registered Number, and on the/..sis a eof I RE-
BY A PERMI / / /�� /
t0 __ 13 (2 oc G�' ./
( ame) (Address)
the � to hold temporarily and the body
(Unler a r 9r person having charge of corpse) (Int emove, or oth wise - pose of (state how))
Dated . .. 2._.5 ne Si 19___ ___ (Signed)
g ) 4cal eg str r_,�,,
This Permit is sufficient for the Removal (and Interment or Cremation) of a 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 _fi -(4---rr2—,-r t was =/'/ '' 19 7 7
(Interment or Cremati )
1 (Name of Cemetery, Crematorium, etc.)
Section A /1 V >7 Lot No. /? Grave No. 2
(Signed) C .4i4--•-Yh
(Person in Charge)
Address ',1s-4 ' 77-7--/---2, 77- -J
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; I`'-
charge," and FILE PERMIT WITHIN THREE (3) DS
with the Registrar of District in which cemetery is loc
li
SEXTONS, FUNERAL DIRECTORS and UN -
TAKERS violating the law relative to the return of per s
are liable to a penalty of NOT LESS THAN FIVE DO -
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.