La Fountain, Rebecca F
1
r /(,rm VS.61. NEW YORK 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 occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No.._ ,79.__
5601 Town
Dist. NoCounty Warren Village 38 Hudson Avenue
or City (If city,give street address)
Name of deceased....Eeb0 . LaFMItaelii
Single, married, widowed,
Sex teliakblor .WhitV.or divorced (write the word).Widowed Date of Death J1311P 19 19.41.
Age 'M Years 4 Months 4 Days Birthplace..CW4
Cause of Death cerebral..Itexuarriaazv 2 l 21 dal.,r.g.pt re arteri u A
_Ce i cate_was_signed by... ...I),P'..... 'loyd.:..Ralmez_ ................-
Address GlenA...Fells..ICE
— -.
Place of Burial (or Removal) TO ,..,oI...Quee •IFY
(If body is to be temporarily held,fill in space later)
Cemetery St..A1.pbnnetls Date of Burial J:1a7t' e...23 19.41
(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 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
to Lionel..J.:•. ..Bt?. .y 0.. 010.6...Z.4. 1,10.. ' .
(Name) (Address)
the II44 QZ:4 .2 to hold tempora" and....... " tRIZ the body.
(UndertakerT or person having charge of corpse) - , die f eta how
Dated R1.wn'e...2O 19...41 (Signed)
Deputy
od Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a by to any part of the State (subject to local
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