Dietze, Herbert 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.
Registered No.
Town, Villa se '
Dist. No. h / County or City .. .-. . . . _
ee � , " If city, give strut dress)
Name of deceased W Veteran D
(If veteran, give name of War)
Single, married,widowed,
Sex or divorced (write the word) ___ to of Death ��19.
Age7 Years Months. Days Birthp}�ce " d-.-!--.y-).ei
Cause of Dth „✓
Certificate was signed by (/- M.D.
Address . . -
y .
Place of Buri•1 (or Removal) '
(If body is to we, porarily held, fill in spac er
'Cemete �_. Date of Burial .. 19 �/
.)}12
(If body is to temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particu ars, having been presented to me, after caret ex ination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I ve accepted t same
for registration, have recorded it in my Local Rec}�rd with the above stat Registered Numb , and on t e b is thereof I H RE
B GRANT A PER i T p/j7�/ , bLeeeteds,n .
•
Name) ^ (Address)
the temporarily and ___. . . the bo y
(Unlertak �: son having charge ., .. se) enter, emove, of ise 9 pose . (- - how))
Dated �► 0... .9._di 7 7 (Signed) °-_j c3 ...=ae�. • • -
II
cal Registrar
This Permit is sufficient for Ail •emoval (and Interment or Cremation) of a bod to any part of the State (subject to local
cemetery or other regulations), u -ss removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) 18A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
91-1
Date of '`1 '14- was / 19 77
( (Interment or Czexsatiattr-
(Name of Cemetery,cezematerivm;"e't"c:)
�_..
SectionI✓ot No. Grave No.
(Signed)
�-
(Persong in Charge)
Address lei" / ` -/' "ea
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.