Shaner, Harold NEW TORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Or 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 nccurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. °' •
� / /, Town, Village
Dist. No. 6 unty [�C/ or City ,
/// �` If ci give street address)
Name of deceased 'a �- Veteran s (-4.-e-
(If veteran,give name of War)
Single,married,widowed,
Sex ....772/ _ et-te- • or divorced (write the word) i(1 . Date o e _.. /D 19 fd•
Age (I_Q - Years ' hs Days Birthplace '
Cause of Death •
Certificate was signe b . . _.. . . . .._ M.D.
Address 9 stieg,az,z2 ' 2
Place of Burial (o Removal) ___ ,
-.447
(If body is to be to rily held, fill in spac later)
Cemetery Date of Burial z' -19 id,
(If body is to bet porarily-held, fill in space later)
The CERTIFICATE 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 accepted the same
for reg'• ation, have recorded it my Local Record with the above stated Registered Number, aAL
basis thereof I HERE-
BY G' A PERMIT' �� // /� / �
--�' !/ f 1 Cam',/ �
( ame�� dress)
the 4....7c....06. a' �L to hold tem oraril and . the bodytemporarily / �'}
(Unlertaker or pers having charge of corpse) (Inter, r •e, or Ather�yfy/dispos f (state how))
Dated �,,1 // 19. (Signed) • L�
Local ltegistr nr
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part o the State subjct 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) (8A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of / tt'4 ' was a 19
�terment or rml,r
v A—‘'
(Name of Cemetery, c,{e ttr m�"trtmlk,,,
1
Section ��'Lot No. ____e.. 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 Iocated.
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.