Butter, Roxann NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 No. 3 /
Town, Village je„
Dist. No.J7g C_/ ty__al or City
If city, give street address)
Name of deceased Veteran
(If veteran, giv name of War)
Single,married,widowed, //
Se----
s__ or divorced (write the word) Date o Death (�- )/ 19.7
Age _ Yea Months D s Birthplace
Cause of Deeath
Certificate was signed by __- .. . _ -Tv M.D.
Address -
Place of Burial or Removal) .. ±--u.. ..._.
(If body is to be -nip. arily:held, fill s ce Iater) f�'
Cemetery ,
/ Date o urial 3a 19.2
(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 reco •ed it in my Local Record with the above st d Registere Number, and on the basis thereof I HERE-
BY A PERMIT ..? .
to ,f7 1 i. i X41,rvVe:...... .../ti
/ / Name) / (Address
the ° , / to hold temporarily and ... s r the body
(Unlert# or person 4 in ch a of corpse) ter, re Tove, or thew dispose of (state how))
Dated 19_._�� ) -
(Signed) —"
g
Local istrar
This P:- it is sufficient for the Removal (and Interment or Cremation) of a body to any rt of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit P mit (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
7P1'47----;
Date of was �.��� ' 3619
(Interment or . .
(j;2(-1
(Name of Cemetery, Cam)
Section V T- �A Lot No. /f Grave No. 7
(Signed)
(Person in Charge)
Address / /a-lir de,
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.