Howe, Suzanne NEW YORK 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. ��`.
Registered No. ,`x"
Town, Vill
Dist. No. �t-)C' I County .60 or City "
-- ----- - ---- - - -- V�� t i give stre
Name of decease 6- _'.-Y1r 1-R./ Veteran_____ ___f�
J (If veteran, give name of War)
�j Single, married,widowed, `
Sex X- _ or di; ;t ;
rced (wr the word) __ - -_ __ _ Date of Dea /-`�-1 19..,1�
Age -- — Y r Mhs Days / -rthplace ✓,
Cause of eath -
Certificate was signed by - M.D.
Address
Place of B or al)
-
(If body is t e t potarily h d, fill in spacV&A11/
Cemete _�(�✓ (,/ �,ur /Date of Burial 7� 19_;�
(If body is to be tempoYarily held, fill In space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same ap 'ng to be COMPLETE, CORRECT, A SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registry ion, ave recorde • in my Local Record i the above stat d Registered Nu e , and on the basis thereof I HERE-
BY GR A MIT
t0 C �
( ame) (Address)-
•
the ___ to hold temporarily and the body
(Unlerta er or son hav ng charge of corpse) t r, remove, h wi o of (s y.1 how))
Dated —' - 192, (Signed) _____,_%
Local Registrar
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) (6A2.130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
� ��'
Date of "Pe was0' '� � �
19 ��
(Interment or Cremation)
(Name of Cemetery, Crw�atorium etr --
Section -C'-re --Lot No. // 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 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.