Saville, Benjamin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
r.:Zir 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 CERTIFICATE OF!
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
, Registered No. lk '
c----sf ‘. Town, Village,
Dist. No. '\---. County '•-k.-)CK.N.. . or City
(If city, give street address)
'-' ,,..A.
,lame of deceased ,„..,..,,,, ,
... ,_...) ,
Veteran
( veteran, give name of War)
Single, married, widowed,
Sex \\\c,-. . or divorced (write the word) Date of Death WY\ cr.- C.:,,, 19 i ]
Age t5 Years . :Months Days Birthplace ..,
Cause of Death , .
Certificate was signed by \,,,,,...,,,C&N...w..„ ._ .; , t.r\ M.D.
(
Address c-1,,,,k,9..-., •‘.---------•
Place of Burial (or Removal)
'If body is to be temporarily.held, fill in space later)
•-,
-emetery \?..-... ..- `s, ,i\t„...--- Date of Burial , Q..s.i,?\ Ni, 19-.),
If body is to he 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 appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
ion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
?ERNIIT
10 C--->• &,..$L.,\..‘.-4--- l., \--\\,)"-I`f\-.,9N (-4•, ---\.\r"-----C-' tiL7t
1Name) (Address)
„...
:he \\N\,&, ..J to hold temporarily and C ..,....."--- the body
(Undirt er or person having charge of co)ru,7) (Inter, move, or otherwise dispose of (state how))
)ated Xe..." -r•-) D 19 (Signed) \--N....:5 •-.--'""
' 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
Dther 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 OR P1;RSUN IN C;tlAttlst,
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 4 was (\ GL /Z'- 19
(Interment or Cremariop),
1-4-7Z
(Name of Cemetery, Cr..matoriam;
Section Lot No. '?/9 _Grave No.
•
(Signed)
(Person in Charge)
Address % � V
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.