Jones, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ate' 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. 4Re '
/. 9 Town, Village xgister�d �
Dist. No. � Q/ Co ty C-�/� or City Cz'=aC.0 .v.
(If city, give street address)
Name of deceased Veteran
(If veteran, 've name of War)
Single, arried, wid ed, p
Sex �ft,,.e(,.. or divorced (write the word) ��Q� � / : Date of Death / 10 197
Age / z Years .Months ays Birthplace
�-
Cause of Death tt L,t'. ���.
Certificate was signed by �;( ,,- ..� M.D.
Address gg �z, .� �� `� Ka...�aLR�
Place of Buri ,�o-r-Remov ,} ,,�- . `....4.
(II ` is s to be,tem temporarily the d j sate )Cemetery Date of Burial f 19
(Ifbody p y e in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after car ful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISF CTORY AS REQUIRED BY LAW, I have accepted the same for registra•
Lion, have reco . it in my Loc ecord with the abov fated Registered Number, and on the asis the f I HEREBY A
PERMIT s / Jithe
to ��
( , me) V (Ad ess)
the to hold temporarily and bo y
(Undertaker or er o a in char a of car e, e...
P Fy, i B 19 (Inter, r ve, oche se dispose of (state how))
Dated r?C / (Signed) ..,,,,„
Local Re istrar
This•Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the tate (s bject tgol�ocal cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is requir
FORM VS. 61. (REV. 6/631 (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN C:HAKCit:
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
it.-i,ht.' ry
Date of ��Z" 1� � � was " " �' 19 / ?
(Interment or Eremat-ien') —
(Name of Cemetery, Crematorium,--etc.)-
Section 1144.1'<t'l Lot No. 9 Grave No.
41%--/C,
(Signed)
(Person in Charge)
r.
Address 1 L
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.