Briere, Noah NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
car This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Viltage, 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.
'. istered No.
‘',5 a Tovm, Villa
or City COW ? 27 --1
v stre'et addre
Dist. No. / County ) ss '
72Z
Veteranf city'
Name of deceased
(If veteran, give name of War)
Single, married, widowed, Cvt4--P--W
Sex ............ . or divorced (write the word) Date of Death ... .1? — . -/". -19 .20.
Age Years .M ths . Day Birthplace
Cause of Death
.....
Certificate was signed by ... ' M.D.
Address
Place of Buri or Reamplp •
(If body is to b t rriporari y , i in space ater t
Cemetery . ..... Date of Burial c,2 — 0 2 19 23
(If body is to e tempor Hy he d, 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 COMPLET1E, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hay recorded it in my Lc) 1 Record with the ab e stated Regi d Number, and on the sis thereof I HEREBY GRANT A
rd c%/, `000; •y
to
(Ackiress)
PERMIT
the ' to hold temporarily and the body
(Un ertaker or,perso having charge of corpse) (I remove the4141Lof (state how))
Dated PI- '-- 9- 6' 19 ..2..- (Signed) •
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to 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.
FOItM VS. 61. (ItEV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of . 17‘12/ was w
(Interment or Crematatt.,
/on)
J / 6.4Z-414.
(Name of Ceme ery, Crematorium, etc.)
Section l L 64ti1* Lot No. fep Grave No.1
C--
(Signed) ( erson in Charge)
6
Address � :5 �cza . �z� 4� ,, 4/• P-
i
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.