Connors, Mitchell 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 No.
n
rb / _ Tow>rVillage LC
Dist. No. County or City
If city, gi a street address)
Name of deceased � ILie- /-� teran
(If veteran, give nam f War)
Single, married,widowed, --�,` p" y
Sex or divorced (write the word) D, Date of Deatji ,��/Q 19,2
Age Years Months - Days_--- Birthplace C''
Cause of eath �Q/L:c -4 r-- _ _
Certificate was signed by _ _ z�r-i M.D.
Address �1Place of Burial (or Removal) 4e,,,,,&:_e_e::,,,li.,,
°� "
(If body is to be temporarily held, fill in c late
CemeteryDate of Burial
// /l 19_2
(If body is to be temporarily held, fill ' space later)
The CERTIFICATE OF DEAT containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be CO LETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registratio , have recorded it in Local Record with< above statedtered Number, and on the basis thereof I HERE-
BY GR PERMIT
t0 'J�'
ame) (Address)
the to hold temporarily and .. the body
(Unle ker or e on ing charge of corps /'(I YY ove, or wise ($ to how
Dated 11 19--- ..�/ (Signed) ` g •
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj t 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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of jfit414--1,4:- was / /i 19 7
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)3
Section PR/EST 3 Lot No. / Grave No. /t
(Signed)
�( erson in Charge)
Address ✓ /�1-'rit_�{ •t ti Olga° -
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.