Griffith, Carolyn 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.
Registered No. __ .2 •
/� f Town, Village
Dist. Ne,�__ ._6.J my_(N" &oitY
- •
city, give street address)
Name of deceased Veteran
(If veteran,giv name of War)
.- Sin e, married,widowed,
Sex or divorced (write the word) Date of each _f/4 19__2
Age �� Years Mo the Days Birthplac , `u J
Cause of Death /Y r
Certificate was signed by • M.D.
-- ---- - - -
Address 7 — ifdi ..v
Place of Burial or Removal)
(If body is to be t rarily held, fill in sp a late r
r
�
Cemetery Date of Burial t.�__--,1 7 19__.77-
(If body is to be mporar ly held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, of r careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS R QUIRED BY LAW, I ave accepted the same
for registration, have recorded it in Local Re ord with th bove stated Re I Bred N„L(i.er, a he is thereofQ [F,tE
BY GRA A PERMIT j
to /A ess)
theto hold temporarily and the body
(lnlertaktz.... ..,..e.:,)teit,„,
na ving charge of corpse (Inter, remove, or otherwise dispose of (state how))
Dated J_.___l_ 19_7 (Signed) 1 egistra
This Permit is ufficient for the Removal (and Interment or Cremation) of a b t e (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a T a el S 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 was /7 19 7,
(Interment or (.Temation) 9
(Name of Cemetery, C. rnalo.iuu.,
Section Lot No. Grave No.
(Signed) & �`
(Person in Charge)
Address j let
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) DAYS a;y01
with the Registrar of District in which cemetery is located.` /�
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permitsC ..
are liable to a penalty of NOT LESS THAN FIVE DOL- f
LARS NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.