Barringer, Daniel 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.
Registereyo, ., 7 1 7
!
/� i Town, Village `/�
Dist. No. 010 County `'� Gn-- or City /�%��, •
If city,give street address)
Name of deceased d / Y`J .)e--1--- Veteran
(If veteran, give name of War)
Single, married,widowed, �,, / / x—
Sex e... • or divorced (write the word) _-/-'f�' RB '
I Date of Death t/ /)-- 19/� _
Age 'f Years Months Days Birthplace •
Cause of Death 4 R A. rn.�_. ... . / f .,... t-
Certificate was signed by M.D.
Address d /
ai_Z le.-/!
Place of Burial or Removal _.. . _ . ._ -X-a )1? .
(If body is to be to pC rily h f' i sp a later)
Cemetery :___ _ 1:7 -L,--v Date of Burial 19__.2;'.
(If body is to be temporarily held, fi 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 ion, have recorde it in my Local Record with the abo stated Registered Number, and on the basis ther of I HERE-
BY GRA A P RMIT
to �.C-C �c.- f � -P 1 j b wr, u.�� j
_
� ��!/ (Na ) / Q4ress)
the t "'�'�4') to hold temporarily and the body
(Unlertaker or p r on aying charge of corpse) (Inter, rem'- or otherwise d• •ose of (state how))
Dated /�J// 19-'f , (Signed) / ;
This Permit is sufficient for the Removal (and Interment or Cremation) of a b I' /o any part oft Sae (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a ransit Permit (VS o. 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 .. f' ,,,, ;. 1`- was / 19
(Interment or Cremation),
(Name of Cemetery, Crematorium, etc,)
Section 4' ' C—Lot No. , J Grave No. __
(Signed) d____-1��_e+_,,tr v>C,
(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 I
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UND -i
TAKERS violating the law relative to the return of permiis.w 't
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.