Buter, Harry NEW YORK STATE DEPARTMENT OF HEALTH / �"'
OFFICIAL BURIAL (OR REMOVAL) PERMIT
(Sr 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 RABLE BLACK INK.
Registered N
Town, Village '
Dist. No. ___ �� Co .r City
/ t If ci giv eet address)
Name of deceased - = G% - ---j Veteran
(If veteran,g ye name of War)
S' gle, married,widowed,
Sex or divorced (write the word) /.7 ate of Dea ---- 19 `�..�
Age
7Years Months Da Bi place � ��
Cause of Death .."-
Certificate was signed by M.D.
Address
Place of Burial (or Remova
g?
(If body is to be temporarily eld ill ' :pace 1 )
'Cemetery �-r� Date of Burial /� 19 ��
(If body is to be temporarily 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 registration, have recorded it in ocal Record with the above stated Registered N ber, a on the basis ereof I HERE-
BY GRANT A PER T
to ,
V,
(N me) (Address)
the /c' to hold temporarily a d the body
(Unlertaker or 1,.....s.gai vm charge of corps ( t , e, or other ise di os of (state ow))
Dated 19_6f0 (Signed). t-''
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subje 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. 6/631 18A2-78)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of h was / 19 8 67
(Interment or
(Name of Cemetery, CritnigirstILIP
Section e71 V\ Lot No. /9S 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 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.