Kern, Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 COM LETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. e
Registered
Town, Village
Dist. No. .,6�•-a Q-1_ Co y aZ�� , or City
If city, give street address)
Name of deceased Veteran If
LU CE>ir
(If veteran, giv name of War)
Single, married,widowed, fr1.,
Sex n , or divorced (write the word) /°l Date of Death h 19 77
Age > Y ar Months Days Birth 1 ce
Cause of Death
Certificate was signe ��� _ , � !
M.D.
Address C-5-- -0-.--- .. e-,- -
Place
of B 1 (or Removal) e a_n„ .
(If body is t beer�mporarily held, fill i> e later) J� /� 7q
Cemetery 1,1.�r+`2.t—c�<<c� // V Date of Burial // 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, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for registration, have recorded it in my ocal Record with the above stated Registered Number, and on the/bas' hereof I H R
BY G A PERMIT � `^/
to - �,c , �
•
( ame ( !.ress)
the ... 6( to hold temporarily and r the body
( nlertaker or pernn a rig charge of corpse) (Inter,Me, o then(se dispo e of (state how))
Dated �1 19 _. � (Signed) -
Local Itegist )
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part the S ate (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. 6i 631 (8A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date °fa- vas /��/ 19��
(Interment or Cren+aiierr-
el-.--1-Lic-
(Name of Cemetery, Crenrale tc.)
Sectio of No. / G Grave No.
(Signed) ��>�� �•/
(Person in Charge)
Address / 1/ et--ey
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.
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