Sawn, John IIICf1I iVKR JIAIC YCrAKIMC191 jr 11CAL117
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. 1$,
Regihered No. 6
Co t
�e 4
Dist. No. _ � p �y or City ,L�^-' �.�----Ft ---�
If city, give street address)
Name of deceased i h S '�-WOVeteran
(If veteran,give name of War)
Single, married,widowed, /
Sex Ntj;_�-4c— or divorced (write the word) _. 6(Yet 0- .a''�_! 7 Date of Death .1 ) 19
Age Af3---- Years i Months �, Days Birthplace
Cause of Death .__3,...4t. _I jj h_t.t: _. �i,t_cf C._/
Certificate was signed b .. _ Olrli ___-_P_ ;,r0,:+p. .l:f-kvt_�r-.__ M.D.
Address 5 et c4e.n �`e_i1��_.,[y__y l fil
Place of Burial (or Removal)
(If body is to be f e 1poraril eld, fill An space later)
Cemetery_.____1___=/_h_C,._ .ei' ‹M c !✓/__Vot✓I Date of Burial _._1 302 19
(If body is to be temporarily held, fill in space latei)
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, t} ve recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY GRA RMIT / / /
to d r F "h G r+! I __Sc: ro re-- /.3 G W.,,,,,si- _, 1�,73fiAkix
,(� (Name) (Address)
the /1 6!t1"'— to hold temporarily and yc uv..— the body
(Unlertakei or pers having charge of corpse) ( , remo or o wiSQdjgpose of (state how))
Dated 1_ .1- 77 19 (Signed) `.�,('��
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of'a oily 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) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
ram .0%,e�
Date of i was 19
(Interment or' --
r
(Name of Cemetery, Cre�aYoriU etc)
411
Section V ` " Lot No. Gray No. 7
(Signed) yc 'V64 &
(Person in Charge)
/ ^ /Address y � C
. . �`
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 STATEMEN ,;.-
write across the face of the Permit the words "No person np
charge," and FILE PERMIT WITHIN THREE (3) DAYS
with the Registrar of District in which cemetery is located.
P•
SEXTONS, FUNERAL DIRECTORS and UNDri'R-
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.
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. / v
Registered No.
Town, Village
Dist. No. �`-' 4 i County or City
fr
/ If city, give street address)
Name of deceased ✓ Veteran
(If veteran, give name of War)
Single, married,widowed, �/ i
Sex or divorced (write the word) Date of Death v�- -�,Kjj 19
Age '-._ Years Months Days Birthplace
Cause of Death �, 44 t t`` Th
Certificate was signed by M.D.
Address
Place of Burial (or Removal)
(If body is to be temporarily held, fill in space later)
Cemetery `� -� Date of Burial � -` 19 7
(If body is to be temporarily held, fill 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 registration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY GRANT A PERMIT
to tam/aa,..._„ . /..s-^---€-
(Name) (Address)
the to hold temporarily an the body
nlertak or per on having charge of corpse) U, remove, or otherw'se dispose of (state how))
Date ._(.0 19_ 1.1" (Signed) --5-9
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body 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
14fria-1/Date o was 19
(Interment or Cremation)
(Name of Cemetery, km ,___
,�—
Section Lot No. Grave No.
(Signedll
(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.
Form VS-67 (rev. 11/65)
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records
FUNERAL DIRECTOR or UNDERTAKER'S REQUEST TO DISINTER BODY
In completing this form, please typewrite, hand-print or write legibly all entries in permanent black or blue black
ink. Signatures should be legible. This is a permanent record. When data cannot be obtained, write "UNKNOWN"
in applicable spaces.
I hereby request permission to disinter the dead body of:
Name of Deca,,ase (r ®-Male Age(Yrs.)
11�1 l� J ,(,pt../ ' 0 Female *
Place of Death (indicate whether city, village or town) Date of ea.h Cause of Death
3
C+ l IL Neil r 4f/ i/ �/ 2? l��y,t :�] ,- 4,,t 7i�,•, _
Ce.yetery no interred 1,ocat' n (city, town or county) Is body to be transported by common carrier?
1 l r /` �,L f1 124 'i)rJ/dv liiii ❑ Yes No
State fully the final disposition to be made of body.
/ P i/ i 11"../C., d
Kale of plac r cemetery for/' final disposition ` j / if
//� Date i al djoppition
r t-IrLe'i.1 t i't.6t') f /��la i1 (..- 1 , 4 Cll 11 w' /"/ ////
F . Now Reg. No. Address
v Pi
jSigna of Funeral Aire or or,Un ert k h Reg. No. Date wiriv"
INSTRUCTIONS TO FUNERAL DIRECTOR OR UNDERTAKER:
1. See Section 13.1 (formerly Chapter XIII, subdivision 4) of the Sanitary Code, relating to the transportation of dead bodies
by common carriers, as printed on the back of the Transit Label.
2. The data required concerning the decedent may be obtained from the local register or cemetery record.
INSTRUCTIONS TO LOCAL REGISTRAR:
1. For bodies to be transported by common carrier, fill out Transit Permit.
2. For bodies not to be transported by common carrier, fill out ordinary Official Burial (or Removal) Permit.
3. In each case write the word "DISINTERMENT" on the Permit.
4. This form should be filed and carefully preserved in your office.
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