LaCross, Ella Form vs.81. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
o! 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......1_.3.. ...._
Village
Dist. No....S.603...County Paz:,:eta or City G.1ona...Falls
(If city, glee street address)
Name of deceased Ella LaC ro s s Veteran NO-
Single, married, widowed, (If veteran, give name of War)
Sex F Color..W or divorced (write the word) Marri.e.d..Date of Death Marerl 3.Qa 19... 6
Age J( Years la Months 2i..Days Birthplace...B.e.e}ft1B.ftQ.Wn,....N.....Yr
Cause of Death Arut.e...4.ocax:d3,.a.7.....l ifar•ct„
Certificate was signed by .P.B.t ....N.,....Bulzaua•.M....D M.D.
Address alexl.a...Falls.r...N......Y..
Place of Burial (or Removal) T.R...Pi...Q,ue.ens.bu.ryi...N.....Y.
(If body is to be temporarily_l)eld, fill in apace
atter
Cemetery t• ((fit P *S Cern, Date of Burial April...2.,, 19...5.E
(If body is to be temporarily held,fill in space later)
The Certiieatp 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 stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to Jam.es...F.....S.i igleton, Gl.ena...Fall.s,....N.. Y.
Undertaker (Name) (Address)
the _..to hold temporarily an .lnt r the body.
(Undertaker or person having charge of corpse) nter, em ,or othe se dispose of [state how])
Dated .A.p..3.1...2, 19..5 . (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (wtbject 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 PEI{SON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date was 4e1r.�? . 19 0-6
(Interment or Cremation)
(Name of eme tery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed)
(person in ch rge)
4-71
Address V i? CC ,✓ d J
C-
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 Lords
"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.