Laroure, Edward Form Qe.eL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
W This Permit can be signed ealy by the !weal 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- Town Registered No—_.. -L/.
Village 4,,,,zDist. No..:.?0G./...County...V./. or City
Ed-l-L-6---4--re
}, (If e!ty, Aire street address)Name of deceased .�l ..2 Veteran -2-2.
��,, /,, Single, married, widowed, of veteran. give name of Wa,)
Sex ' . Color./Y-- or divorced (wnte the word)..../ "'- Date of Death .... . . 19..,..}: &
Age ..�S"-- Year Months......... ..Days Birthplace -, ��:a�i., .� ce_.
Cause of Death . .. .. - .
Certificate was signed by .QZ.tir�:s... M.D.
Address ... . ... . )-%� � 11
Place of Burial (or Removal) 7 it ....�J¢�. . v.'-, -6..... ....At-.A- 4..-o..
(If body is to be temporarily held,dll sacs later) S.
' /
Cemetery r. .o...C2.u.t Date of. Burial /// y��/.•fh)• .., :.t.19 rF
(If bodyis to be temporarily held, fill in• ace later) /.. ...
D Y D ^�
The;Certificate of Death containing the above 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 with the above stated Registered
Numler, and on the basis th I HEREBY GRANT A PERMIT
to7-..
the, . .,,,.. to hold temp :y (Address) the body.
non ker or on having charge of corpse) (Inter,rem ,o e s ,,.: of [state bow]) •
Dated ,...g' 19 (Signed) .... .... i
Local Registrar
ermit,' sufficient for the Removal (and Interment or Cremati ) a body to any part of the State (subject to local
cer.A wry or other regulations), unless removal is by common carrier, in whi case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF S1iXIUN OR PERSON IN CHARGE OF
PREMI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of ( was 19
(Interment or Cremation) ,
1
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
i
(Signed) :�. �/ �-(_ (_ i ��� -
(Person in charge)
Address
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 Lords
"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.