Meilleur, Lucile Form vs.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tT 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 Registered No.._..`-r—
Village
Dist. No �-�
County. .. . ,,,,,e../.."---<,--2V
• I (If etty, give street add es)
Name of decease Veteran
Single, married, widowed, (I teran, given le of war)
EseZ , T77t
t4word) DaisAfirsCertificate was signed b �' M.D.
Address , ' �� v •���...,// ,�
Place of Burial (or/Removal) .. V�� . �_F .---)(If body 1a to be to y . d, • s ��Cemetery.. ,, 4 ... f.. . ..." . Date of Burial. / .N"4 Q. 19
(If body is to e temporarily held,811 . space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above.ated Registered
Ner, and on the basis ,thereof J HEREBY GRANT A PERMIT .- '+
u b �j�
�� (Name) (Address)
e--gun. to hold temp arily and the body.
or person baring charge of corpse) In ,remove,or othe se Mimosa of[eta ,how
V
Dat •... . . i ( i9�i .. (Signed) � ....
al Registrar
•. Permit is sufficient for the Removal (and Interment or Cremation) ofr'a�' ny part of the Slate (eubje to local
Cemetery or other regulations),unless removal is by common carrier, in which case a T ansit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
iiirjil..""m/frt
Date was I•41: Z 19 _
(Interment or Cremation)
£g .
(Name of metery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) 041910
O(J�"' /644".."'Ci
(Person in charge)
//21in2
Address 1C /iG/`74
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re—
quired, under penalty, to report violations thereof.