Downs, Lillian 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 COMPLETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. / 3
Registered No. (�
-� Town, Village
Dist. No. 0( C unty I�C1. City
If city, give street address)
Name of deceased -.-.. ... _ _.. . _._._ _. _. ._._..-. . _.- -ticrx� Veteran
(If veteran, gi e name of War)
Single, married,widowed, //' 19,r
or divorced (write the word) _ .�.2 Date of Death !6
Age 7± Yeas Months Days Birthplace
Cause of Death _____._. __._ .. J�1, a _ _ .
Certificate was signed by C.f/iyrt M.D.
_ ,.,ke.7.
Address
Place of Buria or Removal) .. .. . .
(If body is to b porarily held fiII inn a< later)
Cemetery .._._ . � Date of Burial �// , 19..7,
(If body is to temporarily held, fill in space later) /
The CERTI ICATE 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 accepte the same
for regis ation, have record it in my Local R o with the above stated Registered Number, and on the o,,sis the f I HERE-
BY GR ERMIT zz
to
(])Tame), (Address)
the ��/e��(�/yj�G��JC./[fj.(., to hold temporarily and . .. . the body
(Unlertaker or perso having charge of corpse) (Intel em •e rot r •ise dis se of (state how))
Dated // ?i 7 19 ..2.1 (Signed) _ . .... La
// Local Reg' rar ��•ry, �
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any par of the S ate (sub ct to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 2) is required.
FORM VS. 61. (REV. 6i 63 i 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of was ���19 /9
(Interment or Cremation)"
(Name eter>•, Crematorium, etch-
/ �4J
Section / Lot No. " Grave No.
(Signed)
(Person in Charge)
Address
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.