Richardson, Frederik NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ICE 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.
,) Registe No.
/- own, Villa e
Dist. No; b c-'/ Co Cit ----
. t
__ If city, str et ess)
/12
Name of deceased _.. unt
r Veteran ( c-
(If veteran, give name of War)
Single,married,widowed, f
Sex ___/AX-62--- or divorced (write the word) .. _ } .. Date o eath _ �� 19___ ./
Age Years . oaths _ `ys Birthplace
Cause of Death S ._.
fit/ Y,
g Certificate was signed by ��. M.D.
Address SO W ,i
Place of Burial (o Removal) .__IV ► _ •
(If body is to be temp rily held, fi ' ..ce I.:) "
Cemetery --, l' / : ' _(..4.,/ Date of Burial - 19_2
(If body is to be temporarily held, ill in sp.ce later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same appea 'ng to be COMPLETE, CORRECT, AND SATISFACTOR AS NQUIRED BY LAW, I have accepted the same
for re istration ave rec d it in my Local ecord with the above scat Reg t ed Number and on the b sis thereof I HERE-
BY A ERMIT
t r -..49C4
/ (Name) (Address) -
the _ _ to hold temporarily and _ _--- -.-- the body
(Unlerta er orgerson h jr charge of corgsa er, remo , or o erwi e - ose of (state how))
Dated - 19.. (Signed)
Local R ' tray
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any t of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Pe mit (VS No. 62) is required.
FORM VS.61.(REV.6/63)(7A2.53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
/ - r
k- r
Date of (jv(� �wu v� j," was -�C% 19 7�
(Interment or Cremation)
-1' 47-1-1L,e)
(Nan e of Cemetery, Crematorium, etc.)
Section Lot No. / 5 Grave No. .3
(Signed)
(Person in Charge)
•
Address •
--,'t,:��.) )6,r
ct3 ) .j
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.