Beaupre, Lorraine NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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. ��1, /. / �.l
) Town, Village Re reo��/ j( J(J
Dist. No. 'G d t County LA),04,,,,
YL� or City /
(If city ive street address)
Name of deceased Veteran
veteran, give name of War)
Single, married, widowed, Z/../Sex rda/ . or divorced (write the word) .._.„ ate of Death 'lc' 19 23.
Age �a ( Ye Months
eya/ � . t rth ace ...... .. -�
Cause of Death .... .. ....... .. ... . .... ... .... .... ...... ,
Certificate was signed by .... .. - M.D.
Address 17 'l :-
Place of Burial (or Removal �'..
(If body is to be to rarily he i ace later) !�
Cemetery . Date of Burial J` ,l 19 73
(If body is to he temporarily eld, f• in sp ace later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the
s me appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
ti6n, have recorded it in my Local Record wit the above stated Registered Num er, and on the bass thereof I HEREBY GRANT A
FERMI
to .......... k-
f
Nam ( dress)
the to hold temporarily and(;1
the body
(Undertaker person having charge of copse) (I , remov r oth tse pose of (state how))
Dated 0 -- 7 c)— 19 ..2.3... (Signed)
oval Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to ny 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. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of alicrri-iit was 13 19 73
(Interment or Crematio )
4 ( 0 (
etc.)
(Name of Ce cer Crematorium, e )
Y
Section Lot No. '90 Sc • Grave No. 6
(Signed)
(Person in Charge)
Address Jt �Y .cl-.) .1� 21� d-ok! FLf 16
Person in charge must return this Permit to the Registrar
of his District within SEVEN (1) 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.