Lemery, Lionel NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rir This Permit can be signed only by the Local Registrar (Deputy or subregistrat) 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.
//-- Town, Village Registered No. s,�
Dist. No. Q. / County W c or City -, rtIZ
�, j� ([f city'
give street address)
Name of deceased `� ""' c-' `, Veteran fz U
(If veteran, give name of War)
Sing e, married, widowed,
Sex 71L _ or divorced (write the word) . Date of Death �-.3 e - 7! 19
Age .;i$"- Years '-Q24-/S Month Days Birthplace c,e, .. ..._,,/
Cause of Death -
Certificate was signed by ,Jj M.D.
Address ...wt:,eg-,
Place of Burial (or Removal) emu.•-), grr:z,. .,,,„.7
(If body is to be tem rayily held, ill in space late
Cemetery •.' fe.-Alic-f't Date of Burial .--L- ?p 19
(If body is to be temporarily/held,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 registra•
tion, have recorded it in my Local Recothe above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT A______ �/
to C- �/
7 (Name) r (Address)
the u4;1-7. to hold temporarily atV . .14;;;.:- the body
(Undertaker or person having charge of corpse) (Inter,`remove, other�tse dispose of (state how))
Dated 4 - / 19)7.4 (Signed) -�--) 7 1/- ;.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)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) (9A2-2061 404j60
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 1 was r.. 19
(Interment or Cremation)
ci,tyute-i
(Name of''Cemetery, Crematorium, etc.)
Section S } G, t Lot No. 2 3 -S`•41 Grave No.
(Signed)
(Person in Charge)
Address .5 �� , : :,,y�, /�.tCL', /•
� L
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 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.