Harris, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 N -2 7
�Z�/ ,/ , Town, Village
Dist. No. County !�L/��'��� or City
��nn If city, give street address)
Name of deceased_____________ --__ •._ - /1 AA-� Veteran
(If veteran, g've name of War)
/ Si gle, married,widowed,
Sex .�/ or divorced (write the word) a d-e-t Date of Death /1 3 19.77
Age .Y - Years Months _ Day -Bi h- -
place Lc-i.A.. �. .�f t�
Cause of Death
--- --- - -- - ---- --- - - -
Certificate was signed by �.--A ;7-c •
M.D.
Address .....
Place of Burial r Removal) ..�( . t.Ar
(If body is to be to p rarily held/V 1 in space t
Cemetery Cl (-/ .)_-.._ CAL. __ Date of Burial ��/ 19..772
(If body is to be 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 , have recorded it ' my Local Record •th the above stated
�Reg)istered Numbe i and on basis thereof I HERE-
BtoY GRA T �t lE� 'A, lit
(Address
the („(.....)..c,cittAiNarcat,
to hold temporarily and ._ the body
(Unlertaker or person hayAng charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated f> // 19_.27 (Signed) 74
1.0
This Permit is sufficient for the Removal (and Interment or Cremation) of 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 o was 19
(Interment or matitnl__ __
C-E--2-r—f Y :-'C-e—GCS`.
(Name of Cemetery, Crematorium,-etc.)
l' z'47/
°17
Section Lot N Grave No.
(Signed) - - -..'A-71::-)1.--1-c—.1-2-41---f
(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.