Juneau, Emile NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
«' 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.
// t ' , , '' J Town, Village Registers o.
Dist. No. 86 Gl unty .l�C/.61�1/u2-� or City
(If city, give street address)
Name of deceased eteran
(If veteran, 've name of War)
/� Singl married, widowed, /d am �3
Sex or divorced (write the word) .... .... . Date of Death 19
Age 7 L f Years Months Da s Birthplace....
Cause of Death 4- .
Certificate was signed by ,P9..,../ .. M.D.' ................. .. �. ..
Address .. . .. .. .. ............ / .: .. .. ...�..
Place of Burial (o Remov } y
(If body is to be to po art (' n space later)
Cemetery t Date of Burial / -2-* 19 23
(If body is to-Fe temporart y hel t to space later)
The CERTIFICATE OF DEA 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 r orded it in my Local Reco d with the above stated egistered Numb , and on the ba ' thereof I HEREBY GRANT A
PERMIT
to ��� �� )
e ... ..I�:l."••.••(A. Vies GL'�-'/ )14 ..
theto hold temporarily and the brod
ndertake}•or rson having charge of cor se) p y (Inter, remove, ors t erw 's ose of (state how)) y
Dated /Q .2.7 19 7_3 (Signed) .... ... ./
"� LocarRegigtr
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.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of -Li 1-errr►en f was 0C- ber (P q) 19-73
(Interment or Cremation)
St. Olio 1)onsiAs Cerne,fere
(Name of cfemetery, Crematorium, etc.)
Section Si. f V'e Lot No. Grave No.
(Signed)
(P so in Charge)
Address 3 S +J (OCI d ;±. G 1e)is Fa )) Y
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 UNDERTA tRS
violating the law relative to the return of permits are liab, '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.