Bennett, Zelma NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ggr 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. J//�J Register No. z
Town, Village
Dist. No. 6/ Count/ or City
If city, give street address)
•
Name of deceased Veteran
(If veteran give -ame of War)
Single, married,widowed, ,�
Sex --.�/ or divorced (write the word)�X/�. _ Date f path P o 19.72
Age 7,/ Yea onths Day Birt place ___ ,^Cause of ath '
Certificate was signed by r. . M.D.
i
Address < ay7 .
)\Place of Burial r Re ___ A...X.,e_L---/4---41 y /14 '''' •
1
(If body is to be to t,o<ril, ld, it i s e later)
_ Date of Burial ._.‘ // 19. 77
Cemetery
1
(If body is to be •mporarily held, fi in space later)
The CERTIFI'ATE OF DEAT containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY S REQUIR D BY LA I have accepted the same
for reg' Lion, have recorded it in y Local Recor with t e above stated egist red ber, an the basis th eof I HERE-
BY G A MIT
to e;
( me) ddress)
the to hold temporarily and the body
(Unlertaker or person g charge of corpse) (Ind' ( ove, or h.r '.•e di. ose of (state how))
Dated (� // 19_./ (Signed)
Local Reg- ar //
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pa of the S ate (sfibject 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. 6/631 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of Interment was June 11 197)
(Interment or Cremation)
Wit- Al i hnnsu s Cemetery
(Name of Cemetery, Crematorium, etc.)
Section -y)• r Lot No. rJ Grave No.
(Signed)
(Per on in Charge)
Address 35 Broad St. , Glens TA:111s, N. 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.