Didio, Margaret NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qr 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 ed No.
� / Town, Village
Dist. No:_ Q_7 County V"� � or City a Q__ �� ���
/ If city, give street address)
Name of deceased _.t._ Q-' 1' (t) -C a Veteran
(If veteran, give name of War)
_ J Single, married,widowed, - .� (�
Sex �� 12A-e--- -� - or divorced (write the word) _ _. Date of Death / �S.! 19._,712
Age / , Y1 s M nths Days Birthplace
Cause of Death _____ _ _,
Certificate was signe by f p. M.D.
Address -
Place of Buri or Removal) Z�(.. �.. __. 4c ..__
(If body is to be °ran y held, fi13 pa e later) / _.
'Cemetery .�__ii—V— ,-CAS Date of Burial //Z- t 19.__,7.
(If body is to b temporarily held, fill in space later)
The CERTIF CATE 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 i my Local Record with the,above stated Registered N ber, and on the s's thereof I HERE-
BY G1tA A PERMIT . n
) e4/ . ,„/J-6,
` ( ddress)
the _ {. , -t_ to hold temporarily and the body
(Unlertaker or per on having charge of corpse) (Inter, re v= . other ise disk-e state how))
Dated / 19 21 • (Signed) _ C/ .
This Permit i sufficient for the Removal (and Interment or Cremation) of a bod t '/.ny part of the ate (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Tra sit 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 t was _ Z/ 19 7
((IInterment or rr)------
)V:
(Name of Cemetery, a rrium,
Section £ Lot No. 4- % Grave No. /
(Signed) ( ,-14,t '''
(Person in Charge)
Address /�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) DA
with the Registrar of District in which cemetery is locat
SEXTONS, FUNERAL DIRECTORS and UNDER
TAKERS violating the law relative to the return of per '
are liable to a penalty of NOT LESS THAN FIVE DO
LARS NOR MORE THAN FIFTY DOLLARS FOR T
FIRST OFFENSE. The law will be enforced. Local Regis-1
trars are required, under penalty, to report violations thereof.?