Sawyer, Cora NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Villae stere o.
Dist. No. gal Z Count or City g
/' If city, give street address)
Name of deceased C� 1.(/1 Veteran
(If veteran, give name of War)
Single, married, widowed, ', ',�i
Sex f .„, or divorced (write the word) �� Date of Dea �`� 17
Age / Years ..R Month Days Birthplace..,I �/��,,J l�
Cause o D ath .. . .. . . r,
Certificate was signed y e ' i rpel-444-1. M.D.
.Address /,../Place of Burial (or Remoovval) .... _ �� [(If body is to be temporari a d, m�1�r s cel -
Cemetery ,(/t /(��, c Date of Burial ...,Z, ' tg 197
(If body is to he temporari y held, IF
in space later)
The CERTIFICATE OF EATH containing the above stated particulars, having been presented to me, after careful examination, the
same appeari to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIR BY LAW, I have accepted the same for registra-
tion, have rded it in my Lo Rec wit the above stated Registered Nu r, and on t asis thereof I HEREBY GRANT A
PERMIT
to - e.,t e--=
( me) e s)
the (/ to hold temporarily and ..,. the body
(Underta r or pe s having charge o£epr¢�e) (I er, r e,'or oth 7,o (state how))
Dated 19 0 ( (Signed) ,e 47 /`
Locr.Regigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t,.e State (subject to local cemetery or
other regulations), unless removal is by common corrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-24S)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was - / `� 19 77
(Interment or C-relna-L4444_.
(Name of Cemetery, Et te,riumretc,1._._..,.._-
Section ,R7 Lot No. 4- Grave No. ,-
(Signed) ,p&4vim
(Person in Charge)
Addressf3
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 UNDER-
TAKER 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 UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.