Brower, Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Or 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
Dist. No. 0/ 9,.nty (69.0-44.4,""---)
--‘ Town, Village
or a y _
If city, ive street address)
Name of deceased 0-6..4) 6-14441' - '-1-4---• Veteran (If veteran,vFteran, give name of War).
Single, married,widowed,
Sex /7/(42Q- ' or divorced (write the word) h70-44-e-e--er Date of Death 19_ q 7 ir 7 kr
Age _5 3_ Yeir on s Days Birthplagcal-y . .
Cause of Death
•
Certificate was signed by ..,-(VAA.,...fL • M.D.
Address
( °-' ,
Place of Burial or
(If body is to be t orarily heltifill
Cemetery Date of Burial Pi'9.--, 2- ? 19- 77
(If body is to be emporarily held, fill in space 1 er)
The CERTIFI ATE OF DEATH containing the above st ed particulars, having been presented to me, after careful examination,
the same •e searing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regis ity o n, have recorded itiln my Local Reco with the above stated istered Number, on the asis there I HERE-
BY Gli,'„O' A PERMIT
1 /
to / ',/
art4t-t[41---79) Addres /
the / hold temporarily and .
(Unlertaketmerson having charge of corpse)._
Dated A/ 19. 77 (Signed) the body(In emove or othZet dz of (state how))
40
cal 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) k6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of '''n e'�, was 7
(Interment or C
(Name of Cemetery, Csruaatorium otr)
Section Lot No. ' / L'" Grave No.
(Signed) �i
(Person in Charge)
/Address —r6frio
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.