Champagne, David NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ra- This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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.
Re * tered . /, —6)
/- , , Tovm, Vil e
Dist. No...-,...2.C.)....C.,/ County 60.0A-71-,01../ or City ic1/11-2 y,
f city, give stree addr s)
Li..
Name of deceased ....02c .--t--Z,/`-teel ( ,._____,..r Veteran '. -1 / ..4.')
( -111 veteran, give name of War)
Single, married, widowed, , - )
Sex 22Z0,.„Le.,/ or divorced (write the word) . .3,..if. Date of Dea 3 - 42---.63,A, ...23
Age. 412 Yea7 ....Month .- Days • Birthplace .....,C4.-(-., ,.1 '
Cause of Death ...
Certificate was signed by VyI .7.z.4" 6 M.D.
Address (...-4... (.: , )2, 7
Place of ørjemoval) ... .zi.:72,..,,c.
(If body is to be em rarkly hel , 1 in space at
Cemetery j-:,.4(---vtaL,4 ....6...X:.:-.1,4../ --61-2-1.,4 y Date of Burial 2 - ,: _ 19 2-3
(If body is to he tempoiaray held; fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have corded it in my Local Record with t e above stated Regis red N ber, and on the basis thereof I HEREBY GRANT A
PERMIT C
1(1.. A.4.4 2.„ -;
to ........c.r.),:ci: air ..•.k:214(1•47 .fr9:": .1••
the Z 1 , to hold temporarily an z the body
(Un ertaker r person having charge of covse) Cr, remowr otherwise dispose of (state how))
Dated 2 - a / 19 13 (Signed)
‘41Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t any part of the State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Permit(VS No. 62) is required.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
f\ :2
Date of/ '7`L m/"-1 e 1e/' was '`(/' 19
(Interment or C-rimmatiea)
(Name of Cemetery, ear..sasoa-Lam, ere j
Section e ,:/ Lot No. /% // Grave No.
L/ ,U
(Signed) - 1
(Person in Charge)
Address - ��� L
2Vec Li/ (37 .
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 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.