Langlais, Louis Form VS.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gt This Permit eau be signed only by the Local Registrar (Deputy or aubregistrar) 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.__..
'7, ; !� Village
Dist No /Coua or City .11: <- ,..
Sic
(If city, give street address)
Name of deceased , `.7 e -- A7-` %�..... ��. . . Veteran �iC t
�j�•, //4n Single, married, widowed, / ((f veteran. 'iv name of War)
Sex......•( (....Color P'_' or divorced (write the word). ., 1...f( Date of Death " ` 7 19
Age yfAci Years Months ...Days l/ Birthplace -2i
• p•
Cause of Death . '- �'..-g,....4-,A .... aegeg -rZ
Certificate was signed by ... cc...--... .. ....... M.D.
Address ..... .y....... ..
Place of Burial (or Removal) !la.... ..........
(If body is to be temporarily held,All ins ter) ,
Cemetery i -' 6. '. 4.a...0 z. Date of Burial /// 5- c 19.. .1
(If body is to be temporarily held,fill 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 stated Registered
Num jtttd on the basis thereof I HEREBY GRANT A PERMIT L, / J (�
it 1 (Address)
the �2 � C to hold iemporari:v an. .... .... ... the bodY.
(Undertaker or on having charge of corpse) ,_ •ter, h se di se of (state how])
Dated ir 7 19 (Signed) al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a y to any part of the Mate (.abject to local
cen'etery or other regulations), unless removal is by common carder, in which case a Transit Permit (VS No. 62) ix required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTTEIMENTS OR CREMATIONS
ARE MADE
Date of/at-- -C/L'r„-P--n±was A.)- U . O 19 eT 7
(Interment or Cremation)
(Name of Cemet y, Crematorium, etc.)
Alf,t,1411
Section [ S � Lot No. Grave No.
42„..t...t.94164.<
(Signed) �
(person in ckarp)
Address a t /04')45- /d �f �`mac-^'`-'d
Person in charge oust return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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 FIRLST OFFENSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.