Homan, Richard NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
iSF 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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. /
Town, Village Registered No. d
Dist. No. Il ft1 County ifFA/5S EL' Ffl or City .To isz.N o F HeeL/G/<
(If city, give street a dres )
Name of deceased 8./c-/MBp / H 0 f1 A s)
l Veteran 0 r) ,E4
(If veteran, give name of War)
,y Single, married, widowed,
Sex_._ll. � or divorced (write the word) /y 4RfJEP Date of,Death N,y..1. 19kAge 11 Y Years Months Da s Birthplace.::?4 ENS 1��.3 I
Cause of-Death A'fMA/6'NE5Pi fTOR� its1PP s 1-
Certificate was signed by 5 SILIorg Clio/ l EI M.D.
Address if M* :f/f M H., es P/rr7 L. r n o y MY,
Place of Burial (or Removal) ./N E., _...Y1. cke.7€.R Y Tows; 4F 1. LCfA6 AIRY Nis,
(If body is to be temporarily held, fill in space later)
Cemetery Date of Burial...Je71 2 1j. 19ko
(If body is to be temporarily held, fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to nee, after careful exami-
nation,,the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
tole T r, /1.., o/'EA'* z. S SR V/ce /;7d 0 v E,v 5 r c.LENT Rtl s PY,
the 94IP -T.,.!f/f.`,' e)
to hold temporarily and Ad,
ri rress) the body
( ndertaker or persAn having charge of co se) (Inter,' neer erw• spore of [state how])
.{t Dated.... . a.()j 19 Y� (Signed). _
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cre tion) of a body to any part of the 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) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS o R
CREMATIONS ARE MADE
Date o ),14-c.tryt4as `Jl9
(Interment or Cormatioa
(Name of Cemetery,CAsw -' N, y__,....., ..
Section_ . — t. ''� tNo. "' Grave No.
(Signed) _ _ _ � 044—
--"4-1--"gril
(......
(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 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 Dis-
trict 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.