Beaty, Frank NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
65' 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. C
/ �GLw / Registered No.
�,-�✓/ Town, Village
` QQ
Dist. No. C unty or City Cruz.",.
CO, f city, give street address)
Name of deceased A- -K/ w. .3 Veteran —
(If veteran, lye name of War)
Single, married,widowed, ??cc
Sex __. or divorced (write the word) ..._ - ,Date of Death 19__l2`
Age 7 3 Years Months %ays Birthplace
Cause of Death ,_. t.t
Certificate was signed by _ ripr � M.D.
Address gi /�' /' - t /J�
Place of Burl.. (or Removal) _lt.e¢ t®._-� yc,
(If body is to bet porarily mid, fill i space later) V
Cemetery L� ./.�t Date of Burial 6 19,?..r ,
(If body is to .e 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 app aring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I hav accepted the same
for registrat' have recorde it in my Local Record with the above stated Registered Nudress)
d on the sis thereof F E#iE-
BY GRA caM ze..,71.14_,Z
/ 3 ‘ Z61 _
to 6Na )
the ,t to hold temporarily and the body
(Unlertaker or per on a ing charge of corpse (Inter, -rove, o. otherwi I di e of (state how))
Dated 19_ (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation) of 1r".y to any part o he 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 ' -il'l."74,1-, ` was 'All 19 7`
^'r'�"/�� (Interment or Cremati
(,.1�' Y Le!/t—
(Name of Cemetery, er.tbarhrryt
1, --arr---
t7frk e e./
Section c Lot No. /1'Z/Grave No. _.._
(Signed) /4iri d'`".1"2'11 i
____)
(Person in Charge)
Address / �uil
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 Dili
charge," and FILE PERMIT WITHIN THREE (3) DAY
with the Registrar of District in which cemetery is locat .
SEXTONS, FUNERAL DIRECTORS and UNDE
TAKERS violating the law relative to the return of perm
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.