Fish, Loretta NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
In?" This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
lillage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered o. /0 -
Town, Village
)ist. No. .L...1 et. c) l ounty. le‘ia-AA-LIA--1 or City
e - 11. .
(If city, give s eet address)
dame of deceased .. Veteran
(If veteran give name of War)
-....4'.....-P-D-4(-11"-- . Single, married, widowed,
;ex I,)4461
or divorced (write the word) (/' Date of Death a / ,..- 19 7-,
kge b Years • _Months 2- 4Da s Birthplace.
ause of Death . •
M.D
certificate was signed IY6(--26,4 •
Address
* ...
3lace of Buri or Re val
If body is to b mpor ily , ill in a e ater —.......
.emetery Date of Burial li 19 77
If body is to he temporarily Meld, fill in space later)
['he CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
;ame appearing, to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
ion, have re ded it in my Local Record with the above stated Registered Number, and on t e basis thereof I HEREBY GRANT A
3ERMIT
0 (Address)
he "( ( ame „...L, to hold temporarily and the body
(Undertaker or perpo ing Charge of ciritse) (Lim re.msre, or he wise dispose of (state how))
)ated (Signed) )
Lo 1 Registrar
This.Pertnit is sufficient for the Removal (and Interment or Cremation)of a body to any part o the State (subject to local cemetery or
>ther regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON ON t tNSON 114 c HAxt.x
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of Interment was 4—'17— 19 7
(Interment or Cremation)
It_ %1 phnn gi1$ C ernPtery
(Name of Cemetery, Crematorium, etc.)
Section II Lot No. D-30 Grave No.
(Signed) ce33�-
(Person in Charge)
Address
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.