Streeter, Bernard NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ir 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. L aRegistered No. ._. "!
y /,/J
Dist. No. 6.� County '- (2.4 Town, Village
City
If city, give street address)
Name of deceased Veteran 7}-0
. i .:2.7-. ..�d1
(If veteran, give name o'f War)
Single, married,widowed,
Sex Lfi7&It or divorced (write the word) ..- _ _ ____.______-__ Date of Doh ‘/ 17 19.7
Age ( Year M hs Da s Birth ce •
Cause of Death 2..t9 r�-G� -��
Certificate was signed by ..... . .. - _ . . .., M.D.
Address .2 5
fir.-!, c 1-3
Place of Burial r Removal ,
(If body is to be to orarily held, f i ace later)
'Cemetery Date of Burial q,X2 1977.-
(If body is to be p held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registrat. , have recorded it ' my Local ord with the abov stated Registered Number nd on the Si eof I HERE-
BY GRA PERMIT
(Na ) . ( ddress)
the q- _ to hold temporarily and -_.____- - the body
(Unlertaker or pe sln h ing charge of corps (Inter, re o , or they i. di ose of (st ow))
Dated _ __/_� 19 (Signed) .<. �.
Local Ite rar
This Permit is suff'cient for the Removal (and Interment or Cremation) of a body to any pa 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. 6/63) )8A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of as ` " Ai; /7
(Interment or C
_ r
(Name of Cemetery,
2tit4i'
Section Lot No. al )9" Grave No.
(Signed) a
(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
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.