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Noges, Clara NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT Ear 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. s� Registered N� ��f Town, Village Dist. No. ©l clory �" a/ or City L If city, give street address) Name of deceased X.-� -C -.Qiv- Veteran (If veteran, gi e name of War) Single, married,wid wed, ,77, Sex- or divorced (write the word) __ _7Q114.« Date of each /k/ 19..1_ Age Year Mo the Days 'rthplace Cause of Bath Certificate was___,signed by M.D. Address L.�4-� Place of B rial (or Removal) ,,, .- x_,, (If body is to be t porarily hi� II ins ace later) 1�� 'Cemetery_. _-. - C� L t .c� Date of Burial y 19.- - (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, a ter careful examination, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registration, have recorded i n my Local Record with the above stated Regis ed Number, an on onythe basis thereof I HERE- BY GRA C� to 1 �^` y� (Name) (Address) ,_ the6( to hold temporarily an R'L the body (Unlertaker or petswh mg charge of corpse) (Int , mo r othase ispose of (state how)) Dated of G-7 19-_.. (Signed) Local It istrar / This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any p rt of th State (stlbject 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. 6/631 )8A2-78) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE --- C 47 // 19 7 Date of �'' wass (Interment or , a ion (Name of Cemetery, Crematorium ..tc4---611 Section Lot No. /leGrave No. �j� / � (Signed) A4zAA. a ' " (Person in Charge) Address 7/ / 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.