Weller, G Frank NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tom' This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
'illage, 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.
Town, Village ,, Registered No. e'l'i
)ist. No. S , County..\...%:LUZ .\.S :`� or City ..¢'WJ.. C -
(If city, give street address)
fame of deceased G \s iV1 C r_.; %v Veteran OC--)
(If veteran, give name of War)
, married, widowed,
Single,
____ g
ex ���'m� �- or divorced (write the word)�{ �ti Date of Death ..r. ..........� .1i
19 - •.
,ge 1L' Years .Months , Days Birthplace..\.. '`gl-
'au se of Death ,.,0`1...... . ..+ L
ertificate was signed by 43-'r am N \SN.4 M.D.
Address AM ct,..Q. 3
lace of Burial (or Removal) i
f body is to he temporarily held, fi i spat er)
emetery �.;:f 1,,., ,,.k , ..\.s��s ... .?�:u....an.. 0. ) Date of Burial . 19�.7,.,..
f body is to he temporarily he141 in space later)
he CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
ime appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
on, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
EV.,IIT
- L rh. 4 Vi\\'\rs.Sx1U YN tk...A..c.- C.(S,v4. Ca-`-93 i.'
Name) (Address)
W'`
Le f\&c), - . to hold temporarily and „ the body
(Under a or p rson having charge of oipse) (Inter, , dispose )
{ remove or otherwise of (store how))
ated ............ 19 / (Signed) NC \:k Ca.,,..�=
'-� Local Registrar
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
her regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ORM VS• 61. (REV. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was
(Interment or CsematiQn)
(Name of Cemetery, Cr o orium, etc ) --
•
Section Lot No. dmve No.
(Signed)
(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 retumof 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.