Lajeunesse, Armond NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
[ir 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.
Town, Village Registered No. Y,"
Dist. No. �Q County e or City
(If city, give street address)
Name of deceased —'�-'-� Veteran
(If veteran, give name of War)
Single, married, widowed, ` 7�
Sex or divorced (write the word) 'Date of Death r'� 19 ?U
Age 6 Years Moths - Days Birthpl . �9 �
Cause of Death 1't-lC; «���,�� d-�-ot-�--o/-4-'�� .�->> .,5
Certificate was signed by ... . ,. i `u t'f M.D.
Address 6i' _ ..� �T—C1' •
Lam . /� -
Place of Burial (or Removal X�c�
(If body is to be�}pao�ranl}} h d, 11 ins ce la e )
Cemeteryu-��' �4!Y -4 Date of Burial Feb /3 19 70
(If body i to be temporarily he d, 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 • Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
PERMIT
�ti�e�u✓ XN �� 7
to r
Name) / (Address)
the to hold temporarily a inter / the body
(Undertaker 9r7person having charge of c rpse) remo �/or otherwise dispose of (state how))
..�e
Dated A // 19 .7 o (Signed)
Local Regi rar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the Sta a (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case'a Transit-Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date ol`-' was 19/
(Interment orr-C=iiirrti'ol)" —
(Name of Cemetery, ,
Section Lot No. Grave No. •--_.
(Signed) rc ..
7 (Person in Charge)
Address /"'�1-'i:,,,
, >�7 � - 1✓
Per in char a must return this Permit to the Re 'stra g gl
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.