Winchell, William • NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ESP 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.
J Registered No. `Z S
T, )� or Village / /f Q
Dist. No. ______ 1 CountyCSC/ or City `1 /-�X� ‘ �-
/�,� �) If city, give street address)
Name of deceased �X t��—�)� Veteran
(If veteran, give name of War)
pp -- Single, m 'ed,widowed,
^.
Sex S�— ' or divorced (write the word 7 Date fJ Death l d 19 72
Age 70. Years ___ Months Days Birthplace
Cause of Death >
Certificate was signed by n' / M.D.
.__ M.D.
6 r __-. -�
Place of Burial (or Removal) „, ,����
(If body is to be t porarily helyl,/fill in,s ce later)
'Cemetery_____ ___ ( ___-_L/_tip Date of Burial / ,-- 19
(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, aft careful examination, "
the same ap aring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registra 'on, have recorded it in my Local Record with the abo a stated Registered Number, and o he basis thereof I HERE-
BY GRA AP IT ;
to lc , e.--�C- e--, /' - G %Jj /
/ L (Na e) (Address)
the I/Ktrz%I to hold temporarily andP the body
(Unlertake r person having charge of corpse) nter, remove, or otherwise dispose of (state how))
Dated / 19_-77 (Signed)
This Permit i ufficient for the Removal (and Interment or Cremation) o body to any a 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 PR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date o -'�1 was 19 7 7
(Interment or Cremation)
(Name of Cemetery,Crernrterium_etc)
Sectio� Lot , Grave 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 STATEMENT,: :-
write across the face of the Permit the words "No person i
charge," and FILE PERMIT WITHIN THREE (3) DAY ...
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDER-4
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.