Rozell, Fred NEW PORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I« 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. Ch!
!A/;,..a/-31.-ttkL.1
Town, VillagDist. No.__ 1� v County___ or City�. !L a - --
/ I� �/ If ci y ive street address)
Name of deceased .._. Z,4/-e ,(. ._.__.._ 0-2re_ -� Veteran //�
(If veteran, give name of War)
/) Single, married,widowed,
Sex ____/l or divorced (write the word) _17a'?,-1f--1 Date of Death n - /- 19 -.
Age J4) it Y s __,Months.--- Birthplacey
Days
Cause of Death
Certificate was signed by ... _ ficyl.- t.. v M.D.
Address A_ ,<.__
Place of Burial (or Removal) 17,,,,-Q-sz_b(-,1,...(If body is to be mporarily h (, 'll ince later)
'Cemetery /� .�-, A41, C..t., Date of Burial .1/• —( 3 19_.,
(If body o be temporaril hell, f' in space later)
The CER IFICATE OF DEAT containing the above stated particulars, having been presented to me, after careful examination,
the sam)appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regis ation, have recorded it in my Loca,) (ecord with the above stated Registered Number, and on the basis thereof I HERE-
BY GR NT A PERMIT
I�l. —
(Na e) (Address)
the __._ u. �� to hold temporarily and .!_ :.., ... ' the ttody
(Unlertaker or p son wing charge of corpse) (Int/�we, or erwise se of state how))
Dated fi / 197 (Signed) .
Local Itegistr
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of'the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6i 631 l 8A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of Interment was „T )v• 13 1979
(Interment or Cremation)
+ . Alphonsus Cemetery
(Name of Cemetery, Crematorium, etc.)
Section Lot No. "' Grave No.
(Signed) u —
(Person in Charge)
Address 77d ` . , Gicros :`a: iS ?.Y.
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.