Austin, H Burn NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Ear 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
orT City Villa stere, o. 2 7
Dist. No 6CJ ( Coun 0 or City
'/� '�1G�'�'`� ✓.
`' (If city, give street address)
Name of deceased ..../.4. /�-4e Veteran70
(If veteran, give name of War)
Single, married, widowed,
Sex / or divorced (write the word) Date of Deat 7"/ 1 d
9 2v
Age C� Ye s Months .. D ys Birthplace...........,J1lN-
Cause of Death ���/II
Certificate was signed by ' M.D.
Address V
2/Place of Burial or mova t� y
;If body is to be em arily he , f 1ins ace a� /
�emetery Date of Burial /—cz -0___ 19 ai-)v
;If body 1 be tempor ri y held, fill in space later)
The CE -IFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same aring to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
:ion, ha • recorded it in my Lo al ecord ith the above stated Regi ered Number, and basi ereof I HEREBY GRANT A
FERMI" C//J
( am t -(Adares )
the to hold temporarily and ,y ,, the body
(Undertaker or person having charge of corpse) n remov r o erwise pose of (state how))
Dated /m - a' 19 U (Signed)
Loca gistrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t State (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. 6/63) (9A2-205) 0
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Dater ' ' 4 was '2/19
(Interment or Crem do )
(Name of Cet4y, Caom;ucaitsm.r..,ete...)_....,..,,.,_.._....._ ..
Section Lot No. Grave No.
~ G( A)ifl4iJ
(Signed)
(Person in Charge)
/` eAddress / --+ (9'
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.