Filion, Mildred 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 o. ___ 3 1
/ i / Town, Village`j �
Dist. No. f County (� aJ2 or Cit
i7 C/ If city, give street address)
Name of deceased ''�1�(—C__ Z.Qi iP _ . Veteran
(If veteran, g' a name of War)
Single, married,widowed,
Sex \ 6-- • or divorced (write the word
1-- Date 5 Death 7 19..,V.
Age Years oaths Day Birth ace iZ
Cause of Death C.��Li � �_� :_
Certificate was signed by .,^c_ __ ,/ M.D.
Address -2- —�J-- ._.�"`� a- .__CX
Place of Buria r Removal t -n a--y�4. `/ '
(If body is to be arily held, i 1 in spa later)
Cemetery = __ _ L..t./. 1/ Date of Burial 7 ,l 19._..,7.7-
(If body is to be to porarily el , 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 regis tion, have recor ed 't in my Local Re rd with the above sta d Registered Num r, and the basis th eof I HERE-
BY G A PERMI ,
to ` 7
Name) (Address)
the y to hold temporarily and the body
(Unlertaker or p,/avg charge of corpse) (Inte moorispose of (sDated 19 . (Signed) Local gistrar
This Permit isicient for the Removal (and Interment or Cremation) of a body to any art 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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of cC� Z--�'�.""'M was e 19 .
.��((IInterment or
•
(Name of Cemetery,
Section "Lot No. / eGrave No.
(Signed)
(Person in Charge)
Address /k�✓ / /`�"``
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.