Roethke, Elizabeth NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gSr 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.
" Finty `1. G. gistered No. __ 0 .5.�l� Town, Village ��Dist. No. '� City
If city, give street address)
Name of deceased / c/ M al...--.Veteran
(If veteran,gi name of War)
Single, married,widowed, /
Ser---- � —�"or divorced (write the word) `'� ' Date of eachCil ,� 197 f
Age 7S Ye MQnths ._ ._ Days Bi hplace
Cause of Death .l. -� .
Certificate was signed by __ ._. _... M.D.
Address / 7 ��,�,- , - . .,..
Place of Buri (or R.emov l) _q �,� .cry �cy
(If body is to porarily h y,td�fill in . • e later) a Q
Cemetery_-- _,(.�, (L_,�,Q_tti> Date of Burial 7// F 19....ZI
(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 appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for register tion, have recorded it in my Local R ord with the above stated Registered Number, and o the ba 's thereof I E -
BY GR ' PERMIT \
(N e) (Address)
the to hold temporarily and the body
(Unlertaker or person awing charge of corpse) (Inter, ve, or herw' dispo e of (state how))
Dated 7 ....-/ ._.__.. ..-- 19_.,, (Signed)
Local Registr
This Permit is su ficient for the Removal (and Interment or Cremation) of a body to any part o the Stat (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 ` ?�ry1—,c w4,'' vas c1/4' /g 19 f
(Interment or
(:::Sell-,---• .-
(Name of Cemetery, .
Section Lot No. rav o. 4;er
�/4 ,,�
(Signed) a
( erson in Charge)
Xr-
Address / °'`Z
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.