Winslow, Fredrick NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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 istered No. _27
1-
‘1 J / Town, V illa g� �/�
Dist. No. p/ County w P (-/ or City e,C �
If city, give street address)
Name of deceased fNd.eilc� Veteran �Q ��
' (If veteran,give name of War)
Single, married,widowed, y�� /
Sex 1/�t_4_ or divorced (write the word) ---L!_�_ �. Date of Death (l /6 19...Z 7
Age .__ � . Years Months Da s irthplace T Cause of Death Months,
k-- . _ a-C-4-4/-.. T •
Certificate was signed by - a...,n M.D.
Address .�_ ._._1--6-7c,,,
Place of Burial (or Removal), -p A - _ .� '
(If body is to be orarily held in s ac later) -7
Cemetery - �/ Date of Burial /l /r 19___z_
(If body is to b temporarily held, fill 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 accepted the same
for registr on, have recorde it in my 1 Record h the above stated Registered Numbed on t thereof H RE-
BY GRA A MITit-7
,e<AZA/A-0--e "S, -v-c-e-(__ 13‘ ((l
0 l J ame) (Address)
the to hold temporarily and . ._-.. the body
(Unlertaker or p son h ving charge of corpse) (Inte ove, or otherwise dispose of (state how))
Dated /7 ( - 7) 19 (Signed) �_
// L'al tr
This Permit is sufficient for the Removal (and Interment or Cremation) of a b y 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) (6A2.130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
��t}4L ` /919 77
Date of was
(Interment or
(Name of Cemetery, Crematorium, etc.)
teM de4
Section Lot No. (crave No.
(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 STATEMEN
write across the face of the Permit the words "No person irf•"f
charge," and FILE PERMIT WITHIN THREE (3) DAYS
with the Registrar of District in which cemetery is locatetK.
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.