Demarsh, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
LAF. 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.
4,_,Register, o A c=5°C.,.
Dist. No. _,3—‘0( 51unty 2,a/t/11,- Town, Village
or City
If city, give street address)
Name of deceased YIU-er"-X—My (e, 1A--- Veteran
(If veteran, give name of War)
Sin le married widowed I
g ' ' ' M
Sex ---- e--e.31_ or divorced (write the word) .CLA.4.4....a---et- Date of Death 6 // 19 7Y-
Age 77 Years ff . ,MoN Days i:irthplace
Cause of Death
Certificate was signed by . ..4.--1., k . / M.D.
Address
Place of Buriailifir Removal)
(If body is to be ,orarily held,O)in s ce later)
Cemetery A....4"-P A.44/41 Date of Burial 4/0 19. /I
(If body is to b. temporarily held, fill in space later)
The CERTIF ATE 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 reg% ;$n, have recor d it in my Local Re ord with the above stated Registered Number, and n the asis thereof RE-
BY Gr los A P MIT
to _../44,7l-e-1_,Al
(Address)
,...„.„... ..d.diiel)
the to hold temporarily and the body
(Unlerta(cer or peAo having charge of corpse) (In ern or rw'se dispose s:ote how))
Dated 6 .79. 19.7r (Signed) ,L)
Loc egistrar ______.
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)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
64141/Date of was /./ . 19
(Interment or Cremation)
(Name of Cemetery, C
Section Lot No. 3 D Grave No.
(Signed)
(Person in
Charge) p
Address ' � �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 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.