La Cross, Alfred NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far 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. ��
// ��/�J Town, Village RegisteredJ No.
Dist. No. 04/ County ,,�r;�G2�'1� �./ or City /✓ J a—
If city, give street address)
Name of deceased X oS�1 (-��—Q� Veteran
(If veteran, give name of War)
--�,, Single, married, widowed,
Sex �`�d or divorced (write the word) ".,�- — Date of Dea h 4'4, 7 19 '''7�
Age ,5.?--- Y3.rs ,A¢onths Days �,/ Birthplace C% �
Cause of Death L" -�� (—v P.izc� / 6,yy;,� .1
Certificate was signed by 71.4.......n., M.D.
Address fi -2
Place of Burial (or --Removal) i7- 72- pP ,
(If body is to ./ -mom. .+' • -e d, fillv
in space I r)
Cemetery ' / ,,r1,. Date of Burial G /Q 19 7lJ
r
(If body is to be tempo. ily held, fill to 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 cal Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PER. �,�
to . 1r � .�Gr%� v -(�.i., k../
�/ „-- ( adress)
th l/G to hold temporarily and )1-'� the body
(Undertak r person havin charge of corpse) (Inter, remove,-orr otherwise dispose of (state how))
Dated 8 19 7� (Signed) .. ... -s'a� ��....�1 ....
Local gi r
This Per a is sufficient for the Removal (and Interment or Cremation)of body any part oft Stat 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) (9A2-205) •-�` -`-•0
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of �' was �t,�/►tQ. 10 19 76
(Interment or Crema n)
(Name of emetery, Crematorium, etc.)
Section >3(P 1 l Lot No. 13 Sit Grave No. I
(Signed) .2�.
(Person in Charge)
Address 3 G , j ✓W"`�', v. I.
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
fade 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.