Lapier, Josephine Form vs.si. NEW YORK STATE DLPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed may by the Local Registrar (Deputy sr subresistrar) 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. Town Registered No—.._.6— ._.......__
/ Village
Dist No 51,01 County........1.�.v.. 441.. or City } '�
n �M� (If e1t3', the street address)
Name of deceased i1JV•' X Veteran --�
Sin le, married, widowed, ,,,,// OE veteran. give name of War)
Sex... Color IN or ivorced (write the word)..`/ Date of Death --Li/ D 19 s
Age l6..4 Years L�J M the. Days Birthplace .... .},?..1.
Cause of Death 4�1aiY!!4 `.... 7
Certificate was signed by !".A-CkVt.
. . y" gyp ��jj M.D.
Address ir-i.1 ..ht-- , � n '�
Place of Burial (or Removal) . " ... '/
(If body le to be temporarily held,fill to s a s later
Cemetery 1 6.h.... Date of Burial /-�/3 19 's1
(If body is to be temporarily held. 11 in space later)
The,Certificate of Death containing the ab ve stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record withQ the above stated Registered
Number, on the b`ais the f I EREBY GRANT A PERMIT itat4 )P''v`_ 'to at 1
•
the . (Name) Address)
to hold temp rily-and the body.
(Undertaker pr person having charge o1 orpee) Int ,r e, otherwise dispose of[state howl)
Dated .'UV 19.. .55. (Signed r ��alA�
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (eubjeet to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was J/1/ . /3 19 c r
(Interment or Creme. ion)
(flame of Cemetery Crew •rlum, etc.)
Section Lot No. Grave No.
(Si del)
(Person in charge)
j2-4 Address Fe.e,/e/g4L'
.-7/1./t(1
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re-
quired, under penalty, to report violations thereof.