DuFour, Anna Form V&leL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
do- This Permit eau ha 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...../ /
/ Village /
Dist. No.. 6.4...Coun ....../1.aks�.1.Cezz� or City ¢.•- ( E2•
'712 (If city, give street address)
Name of deceased Z.t,4,.... ,. *4.c... lrcrG�`- Veteran -Q''
Single, married, widowed, ��, (ff veteran. give name of War) _
ee
Sexy'' Color or divorced (wnte e word) -�� i°`�" Date of Death 1 z c` 19'
Age ...� Ay�,ars 2 Mpn ...£l Days. Birthplace -�'c.--�
Cause of Death./;.b.Z. :: /... ism .
Certificate was signed by - �-�e �� M.D.
Address — '1! G_.
Place of Burial (or Removal) �,2sz/(/ ;cam Lg'- .
(If body is to be tempo arily�b,eid, 1 space later) j _
Cemetery . .,....Gcte�. .. ti-;r+--; .-C.Ii3 . r Date of Buriali...-(_.4/,4-e--- 7/ 19 V r-
(It body is to be temporarily hel fill in space later)
Thq 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 Reco d with the a e stated Registered
Num. , . ..• on the basis th creof11 HE EBY GRANT A PERMIT
to... .1 ' 'tom'- '"`' `Y iv J4.4.uvkz-c�..1.--s..� G't':--,
the -`�r" to hold temporarily and the body.
(Und taker or person)'aving charge of cor Inter,re ye,or oy�erwise Mimosa of[slats bowl)
Dated I/ 19..,.. (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pact of the State (subject to locrl
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 of lk1 ( .yi Jh ' ;L, 19
(Interment or 'Cremation)
"1
t ,4
Ir it .'"7 r�
(Name of Cemetery, crematorium, etc.)
Section(') / + 1( 1 ,/ Lot No. r S. Grave No.
f
1.13ereon int arge)
yf
Address .J .J 'y ) 1!i T` C At
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 wards
"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.