Davignon, Bennard 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,
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. � �--
_ / i Town, Village Regis re o.
Dist. No....., t/y..Q..i County l - "r 1` ''--" or City
/ (If city, give
,street adds
Name of deceased7 . ........... &L ' i .,:.6�(/`e- JX:: 1/L- V teran .ic.J Ze‹...)
(If veteran, give name of War)
Single, married, widowe ,
Sex / > or divorced (write the w )/...I.. Date of Death ../... A'619 ...rl.
Age Z U Year � Mo the Days Birthplace
Cause of Death Year',
`.. Y.3.(47-ik, 211(-- _,
Certificate was signed by /7 , I- d .. M.D.
Address /�/ •
. ................. ,/,/4
. .. .. .
Place of Burial (or Removal) c.J� V.I �' c�.
(If body is to be tempor rily a d, in spat tey )
Cemetery . -D 4 ......... .�.-/-c Date of Burial is - c ?c 19.7,�...
(If body is to he temporarily held, ill in space later)
The CERTIFICATE OF DEATH containing the above stated particul rs having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY REQUIRED BY LA ', I have accepted the same for registra-
tion, have' recorded it in my oc I Record w h the above stated Registered Number,and o the basis t e eof I HERE Y GRANT A
PERMIT /
/` (JIL 72 /
�� dressy /
the to hold temporarily and ��
(Nam the body
(Undert 'eror ^erson; aving�arge of c se) (I remove oth se spose of (state how))
Dated ',..C..�,..?. / ,. 19 (Signed)
dr4 =strar
a
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to y part of t..e State (subject to local cemetery or
other regulations), unless removal is by common currier, 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 / //‘ was / a 'Y „=,9
(Interment=orC--ren+a roa).
(Name of Cemetery,--.a ,,,�, ---
Section Lot No. Grave No.
(Signed) 1 a' �`
(Person in Charge)
Address /C// ,'"% e—_ ', '
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 UN '—4 -
TAKER MUST SIGN ABOVE STATEMENT, write across t .-
face of the Permit the words "No person in charge," araii.`
FILE PERMIT WITHIN THREE (3) DAYS with the Regi tr r
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liablelo
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.