Rising, Anna 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. LJ
� Town, Village
'
Dist. No. �(a U C unty or City :..
/ If city, give street address)
Name of deceased (�1-./,L--el , . /-r¢z Veteran
(If veteran, giv name of War)
7 7
Single, married,widowed, 4)
Ses Y or divorced (write the word) '-e—e'll Date of Death 19 _y
Age Q-/ Years Months Days Birt ice
Cause of Death, _. . ".. c7�
Certificate was signed by M.D.
Address
Place of Burial (or Removal_ -V , )?--.
(If body is to be t mporarily held, fill''spa_c lat
it
'Cemetery Lt./Q,:-- � >`� tt� Date of Burial `7/0 19. . 7
(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, II have accepted the same
for registr ion, have recorded it in my Local Recor ith the above stated Registered Number, and \fthe basis reof I HE E-
BY GRA P RMIT
O_ , -
- ---- ------ -
Name) (Address)
the Ct�4o hold temporarily and _._ the b6dy
(Unlertaker or pars n having c age of corpse) (Inter, e ve, o therwi , ispose of (state how))
Dated (l/_/_U 19_.. (Signed)
Local Registr
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part o the St a ( ubje to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 2) 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 G� L � 19 77
(Inte ment or,.&rematiaua
(Name of Cemetery, crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(Person in{ Charge)
Address /t957. Li .. e ee.
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
with the Registrar of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.