Hermance, Lester NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rir 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. /6
,,((/� �l / Town, Village Registered No.. ��
Dist. No✓e..0 t County .../e C�../�/L � or City ` 7�E�--
(If city, give street address)
Name of deceased (-(C l ��Cr2: 4G��Jeteran
(If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) ..'.,e4,-- CQ Date of Death .. — 7 197a....
Age 6. / Year Mo the Days Birthplace /�� ... ....1
Cause of Death ....
Certificate was signed by ;,,7 r Z� M. .
Address /crc -2-- it'`f' �e .
i )2 -/ '
Place of Burial (or Removal f
f body is to beil} h d/ pack lat}4;',%%
Cemetery t...., k Date of Burial lQ 197 O
(If body is to be temporarily eld, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after car Kul 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 Record with the above stated Registered Number, and on the basis ereof I HEREBY GRANT A
PERMIT
to 4!�'-/� `✓�( me)n r��1�6-C' �' `.�P --e� `-�ddress��� � ) C
the -e-e-eZei[.-7 � 1'4-' to hold temporarily and �1� � t e body
(Undertaker or person having charge of corpse) Inter, remove, or 'tjrwts �ji�sf ose o (state how))
Dated — e- 19 70 (Signed) ✓'/...1.- it/( l tl-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permi (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (9A2-2051 `� --_•9c
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of<gia:4'1:' as ////°' 19 74
(Interment or r'.a,4041^.t
Name of Cenl'
( etery,
Section Lot No._ Grave No.
(Signed)
(Person in Charge)
Pefson in charge must return this Permit to therar
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.