Conran, Eugene NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
air This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
/illage, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CE TIFICATE OF
)EATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. f ?
!D / / i Town, Village Regi c cJ
)ist. No. ,.. - County . . or City q 3
(If city, give street address)
Tame of deceased /7.,4--t Veteran
(If veteran, give name of War)
Ingle, married, widowed,
;ex or divorced (write the word) Date of Death .... �' 3 19 ,i
ge 64 Years/..,) Months eta_,,,_,A,,,,
Days ,g� Bie
:ause of Death �" • . i .. ao: •:ertificate was signed by , . . M.D.
Addressy ... ll�. ... ., .
'lace of Burial ( Removal) .t ....
If body is to het orarily- held, f i space later) �� / 19.7�
emetery �Et1 c P.` � ate of Burial // 3
If body is to be•temporarily held, fill in space later)
'he CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
ame appearing to be COMP ETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra•
on, have recorded it in • Local Record with a above stated Registered Number, and the basis thereof I HEREBY GRANT A
ERMI
Na.0' (Address)
1e - ,, to hold temporarily and the body
( dertaker7gijg chge of e) (In ovoe wise dispose of (state how))
ate. 19 (Signed) .l ,,
Local egistrar 1
This-Permit is sufficient for the Removal (and Interment or Cremation)of a body to any parr of th State (subject to local cemetery or
they 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 SEX1km UN Vt.KJUIN API Lnttr UE.
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
/
Date of . �/& 1" t " was // ''"---- 19 //
(Interment or.£-rencatioe)
(Name of Cemetery, Crematerium,-ete-.)------
Sectio ' '" 61 ) Lot No. :"2---'�Grave No.
4(Signed) --Y �""' „--i—'
r (Person in Charge)
\__ f ''
Address ()- j ' }_`�- �`k_ .
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.