Combs, Catherine 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 COMP ETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Regi to ed No.
/ ) Town, Village
Dist. No 0 unty ( or City
If city, give street address)
Name of deceased (�� Veteran
(If vetera , give name of War)
Single, married,widowed, 7j p
Se or divorced (write the word) ' 11 %'C�.c r�-_:. Date of D at 7 • - i 19.70
Age 6 Yea Mont Days Birthplace
Cause of Death , _ °
Certificate was signed by - 9 . M.D.�.
Address 9'.D. _ - y � / /&-ge-- c,,..jag-,
Place of Burial Removal) dC2�,.d
------ -- -- - -- - -
(If body is to be to arily held, fill,1 sp a later)
'Cemetery Date of Burial V,2 SC 197 — ,
(If body is to be t m oral n s ily held, fill ipace ater)
The CERTIFIC TE 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 record d it in my Local R d with the above state egistered Number, and n the basis thereof I HERE-
BY G A PERMIT . ` =x
tot .c.14 ky.
(N e) (Address)
the to hold temporarily and ..... -_ the body
(Unlertaker or pers having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated //. '3 19.7. (Signed)
.e.• t ; . J
This Permit is sufficient for the Removal (and Interment or Cremation) of a •• a • • ` - bject to local
cemetery or other regulations), unless removal is by common carrier, in which case a � sit Permit (VS I. • is required.
FORM VS.61.(REV.6/63)(1A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date off 11---M-C4r was 19 2g.
(Interment or
(Name of Cemetery, CtiltfCato r,-etc:j'
Section -e,« `�Lot No. Grave No. `
(Signed)
(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 i
charge," and FILE PERMIT WITHIN THREE (3) DAY
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permit del
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. '