King, Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ir:4IF'' 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Regist ed
Dist. No. ,..5c.i.01 County a,ia.44,4-„—i or City
( f city, give street addre_orr,ss)
Name of deceased .4°0---4-4.--/- .i4f- (...7.--- Veteran ..4-0 41 e2)-14--'
(If veteran, ive name of War)
.
Sex 2.2W.,e— - Single, married, widowed, i27 '
or divorced (write the word) - Date of Death / 2- e 19
Age —37 Years ty .Months
Days Birthplace
Cause of Death - "
Certificate was signed by 441 Xi'i
M.D.
Address
Place of Burial
7i4 Removal)
,If body is to be
emetery orarily held, 1 , n space ater t
inDate of Burial 19 7k .
:If body is to b temporari y held, fill space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented CO me, after careful examination, the
same appiing to be COMPLETE, C RRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted t same for registra•
:ion, hay. orded it in my ocal cord with the abov?e sta d Registered Number, an on the b •s
ress thereof EREBY G AN,,,T A
PERMIT
( a
/ " •
to
(Na e)
the • to hold temporarily and they
(Undertaker Ipso 3a_vjg c arge of co
Dated 19 (Signed)se) (Iyemo , or erw se dispose of (state how))
X (..k.cty
Loc Registrar
This•Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t e State (subject to local cemetery or
Dther regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN UHAK(L
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Ag
Date of was 19 -
(Interment or Eretnacien)--.---
(Name of Cemetery, Csre atorium, etc.)
Section /71-11tr-tea Lo Not..A.3 4 _�Tarave No..
Si e
(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 UNDER-
TAKER 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 UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.