Hayes, Leslie 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,
tillage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village Registered No. ....�j
)ist. No. ..�..4;�:.\`..... County \..?...C,:N -'C or City 4.- Qr`C". C S
(If city, give street address)
lame of deceased .. \ '•4•.• Veteran .C.3
(If veteran, give name of War)
Single, married, widowed,
;ex . C.. or divorced (write the word) Date of Death 191�
.ge .C.) ...,yearsM �-�.r.onths Days Birthplace\ ?.3 `ic,'-i4.,,,,
:ause of Death .\ Vc..../51-14-?..r---
r
:ertificate was signed y` Cry-^N`\.).-4 d CL.. M.D.
Address 5 ..,.1 1.
'lace of Burial (or Removal) .;N.
If body is to be porarily held, fill in space later
.emetery -U>1....\, ..."' .n c:,. N,,., Date of Burial Ed,.-.6 19 1 Q..
If body is to be temporarily held, fill to space later)
:he CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
ame 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
'ER\yt3
o kt.C}. !\... `4.'ss R ( =.-.,:s, N
(Name) (Address)
he �,,' ,, �Q,, .,�Q... to hold temporarily and ...,t. ,;\\ ,. the body
(Undertakor persion having charge of camse) (Inter, remove, or otherwise dispose of (state how))
>ated •;.4 19 ...2........... (Signed) `(' 5... ---
ocal 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
Ither regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ORM VS. 61• (REV. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON UK rt,tc uN iN LnHrcua
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of li7T'f?Le-r;%f was 1`'`-.?"- (,' 19 "
(Interment or Cremation)
--
(Name of Cemetery, Crematorium, etc.)
Section - ti Lot No. % Grave No.
(Signed)
/ (Person in Charge)
Address %'✓ fir A` :fry
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.