Stubbebine, Charles 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.
o 21lee
Registered 'D
/ ��/��� Town, Village
Dist. No. ,-9�/ County ( L or City
- If city, give street address)
/�
Name of deceased P j 'l- -� S7t.-/6.0,161-6---k - Veteran
(If veteran, give name of War)
Single, married,widowed,
Sex ._._ or divorced (write the word) _. . ._._ Date of eath ?I /,7 1977
Age Years . Months Days Birthplace _... ,,.e/n��
Cause of Death
Certificate was signed by M.D.
Address --- - - x"`
Place of Bur':. (or Rem ova
(If body is to b porarily hel , ill in spa ater) % r--
Cemetery_____gip Date of Burial _1 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 appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registration, have recorded it •n my Local Re rd with the above s ted Registered Nu er, and o the basis thee HERE-
BY GR 'A PERMIT
to )e, X t='4 •
e) (Address)
the to hold temporarily and -1----t- the body
('Unler ter o per n havin charge of corpse) (Inter, remo of a ise dis state how))
Dated /7 19_ 1. (Signed)
cal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body o 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
Date of '`" el/f-' was c �"`-i" -/'197 _
(Interment or C iemaiien}---
I2-1 i'' .tytn �t' oil
(Name of Cemetery, or um, etc.)
Section i Lot No. X J Grave No.
(Signed) N4-41-1%.1 X-7-1-7-----t12/
(Person in Charge)
Address /&^' gG /'6 '
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 locate
SEXTONS, FUNERAL DIRECTORS and UNDE
TAKERS violating the law relative to the return of pe •
are liable to a penalty of NOT LESS THAN FIVE D• f
LARS NOR MORE THAN FIFTY DOLLARS FOR T • F
FIRST OFFENSE. The law will be enforced. Local Regis
trars are required, under penalty, to report violations thereo