Dubee, Leonard NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rar 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.
egtstered No.
1 Town, Village
r
el
Dist. No. � CountyC�.. A�ti° �r City
�A /,/rlf �a
, /� (If city, give street ddress)
Name of deceased `'`0-1 ,1,.�,,,Lx„. -,,5z- Veteran
i (If veteran, give name of War)
Single, married, widowed, '/ i c
Sex or divorced (write the word) ... Date of Death
Age Years Mon Day?: 'rthpla
Cause of Death = tivZ a--z--e' - .-e....rt- -r-%
Certificate was signed by ......,... Cl':.��•.•,n.... .G$,.f���.,Q,,,�„rr. - M.D.
Address e--- 6 -C- r
Place of Bu, (or Remov l� /0,-- .� ( (?
(If body is to b .mporar y e d, fill in space later) ' j "�
Cemetery .:. .. .. ... ... Date of Burial ,./, .
(If body is e temporari y eld pace later) x < F 19
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, afer careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded tit in my Local Recoo d with he abc,ve stated Registered N b r, and on the basis thereof I HEREBY GRANT A
PERAto
. 'ate 1``=,
(Name) • n (Address)
the to hold temporarily and
ove, r the the body
(Undertake or p r o sing charge of gr se) ;rem rw d o of tat ))Dated 19 (Signed) �
Local Registr r
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local ce tery or
other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 8f. (REV. 6/63) (8A2-205) 91
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
C� ��
Date of ��{�b//��as // 197 e/
(Interment or r.. -, a4.i.Q-.)�
(Name of Cee etery,,G •^ ` —
Section Lot No. `' Grave No.
C�
(Sir('
(Person in Charge)
gAddress
Per in charge must return this Permit to the RI::
of his District within SEVEN (7) DAYS from above date. If n,,
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.