Kenworthy, Lisbeth 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 COMPLETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. -�,f
Registered No. /(?.
•
f Town, Village �
Dist. No. -5-6 C i County �a � or City C. Ty 6/"L�"' ��
// If ty, give street address)
Name of deceased.L 4.16 e 4. �e�i, 1611-may Veteran NO
(If veteran, give name of War)
Single, married,widowed,
Sex F - +alp or divorced (write the word) W. <lie u)e- � Date of Death T i 0 19 71
Age .? Years Months Days , Birthplace __-/Il v Ior/C S e
Cause of Death ✓i S/1 Z W t._ Cep ,,-.10 :- 7 i _ _ /
Certificate was signed by /ter n x //
- --�----/1. !l� � .,.1. _a_/ M.D.
Address 90 - O,4414 -1 T --_ l•a i/ree _ivy
Place' of Burial (or Removal) T_ut - id._.e- - -41-4-s f A/
(If body is to be temporarily C..cam _K Date of Burial Z- 19.7P
(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 recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY GR7r A PERMIT /n _
to ✓l / ....,n fne) �'l Ci i N. l a1 r�-� .s 1f cc-1 t� /
(Add
ess)
the l n.---- a_1Li.v to hold temporarily and -rn.�-. -� the body
(Unlertaker osufficient
rsoqq hvjylg charge of corpse (Inter, remove, or otherwise dispose of (state how))
Dated l /// 19_../.._ (Signed)
This Permit for the Removal (and Interment or Cremation) of a 1114441401rb
nyject to local
cemetery or other regulations), unless removal is by common carrier, in which case Permit (VSrequired.
FORM VS. 61. (REV. 6/63) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was __ 19 21
(Interment or Crematio
(Name of Cemetery, Csettrdtoriurn etc.-
`Nlmr a t 6) `5 /
Section /9 Lot No. 7 Grave No. G�
(Signed) c7C -------
(Person in Charge)
Address /4 / "elr .
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 ins'.
charge," and FILE PERMIT WITHIN THREE (3) DAY'`
with the Registrar of District in which cemetery is locate.. '
I
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permi.
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR TH
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.