Smith, Rayadan NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itg5P 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.
gistere No. r' 3
Town, Villa
Dist. No j b.G L-- - - County_ZA)._Ci�.1nile or City yF _ yC%�.
If city,,,give sty
ee ad ress)/
Name of deceased.. __. _. . Veteran .i
(If veteran, give name of War)
Single, married,widowed, /
Sex ?yiaL2-- or divorced (write the word) -- - - - - -- Date of D ath l � 19Age Ye: Months _.. Days Birthplace .R:4c_1.._cl
Cause of Death _ _
Certificate was signed by -._ - � _.� ... _ .. M.D.
Address ,P.�.f/
Place of Buria o Remov 1)
(If body is to be orarity helc, 11 in spat ajar) 7�
Cemetery .L LQ Date of Burial / —�� 19._2
(IF body is to be temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,
the same pearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regist ion, have recorded it in my Local Reco with the above st d Registered Number, and on the basis thereof I HERE-
BY GRA ERMIT•
to )2 °(
(Name) (Address)
the v to hold temporarily and the body
(Unlertaker or person having charge of corpse) (I ove, o(k ise ,pose of (state how))
Dated I "' ,? 192- (Signed) ._.. _. . -
Loca gistrar
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 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 "`'Z m�{ was ile 19/ q
(Interment or C
(Name of Cemetery, r)"'
anai,(443 X/Jr. rfr
Section Lot No. 7 7CGrave No. f 6
(Signed)
(Person in Charge)
Address £'e, L i�"�'L t
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.