Figueroa, Victoria NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1' 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 o.
Town, Village
Dist. No.��0) ounty__-0 --.- -- - - or City
/ If city, give street address)
C
Name of deceased A �1,,,C. _ - 44.1Ar - Veteran
(If veteran, give name of War)
Single, married,widowed,
Se __ __-_ _•_ __. . or divorced (write the word ___ :. Date of Death __
Age __._ _a • Y s Months s T. hplac 7--y •
Cause of Death
Certificate was signe by _ M.D.
Address �' ._ - - - -� -
Place of Buria or Removal y��e _. _ d
(If body is to be porarily hel i in space later)
Cemetery ,e i��La —' Date of Burial 19__.73
(If body is to 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 appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regist on, have recorded it in my Local Record th the above s ted Registered Num d o e basis they of I HERE-
BY GR A PERMIT
to ------
14 ' 7
(Na e (Address)
the ___ . __ _. __�_ _ -._ to hold temporarily and JL-7,...--6,-t_. the body
(UMrtaker person having charge of corpse))/ (Int , ree, or otherwise dispose of (state how))
Dated _ Y 19..7/ (Signed)
a
This Permit is s cient for the Removal (and Interment or Cremation) of a 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
Date ({ '2-19 7 7
(Interment or (pomatinnl__-
(Name of Cemetery,
Section Lot No. / /)Grave No.
_
l
(Signed) >> 2--ve
(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.