Fugazy, Austin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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. `7j"0?d
•
i Registe No.
Town, Village
Dist. No. t�/_U_/ ounty w M/W" — or City.
If city, give street a dress)
•
Name of deceased _ _._ _ _ Veteran __. 61••) 2
(If veteran, give name of War)
Single, married,widowed LR
g ��yy
Sex jj __'.... _._ . or divorced (write the word _-_ 1/i.C, Date of Death iU �-3 19.1__Age b 0 Ye nths D irthplace ,_- •
Cause of Death `��•
Certificate was signe y Q M.D.
Address
Place o_f Burial or Removal) -- / �_~ r
(If body is to be to or rily held, fill in space later) G
'Cemetery .._ _. _ _. Date of Burial .7/0. _..z___._.__._._..__- 19___7
(If body is to bet p rarily ehl, fill in ace later
The CERTIFICATE OF DEATH co aining the above sta ed particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUI ED BY LAW I have acc:•ted the same
for registdill• , have recorded it in my Lo 1 Record with the above state. Registers tuber, and o th basis i ereof I
BY GRAPE (�/
to 0j 1Lc
(Name) (Address)
the to hold temporarily and the hod
Wrilertaker o erson vinr�harge of corpse) (Int, / ,ov or o wise ispose of (state how))
Dated / 0 .1- 7 19 , 7 (Signed) /_‘_
Local istrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any p rt of the tate subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS o. 62 is required.
FORM VS. 61. t REV. 6/631 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of 'r1;r_,Y^rn�;r�t; was Oc.+cb r. 25 1979
(Interment or Cremation)
�. ,
(Name of Cemetery, Crematorium, etc.)
Section L., Lot No. Grave No.
(Signed)
son n Charge)
Address 7 '1 -+ - , Gl An S Fa 1 1 NY1?ROII
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.