Landry, Lawrence Form VS.e. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit ran ha 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. Town Registered No._
Village �i
Dist. No County..._... ..1�1.-.Lif!!�- 4or City ,,�.�,F�c'Y�-.; ,�� -� -i
(If city, glee street address)
Name of deceased.... .....11 ... Veteran
(If veteran g t name of War)
Single, married, widowed, _ .
Sex... .......Color [ or divorced (write the word) . .. . .. .. . .Date of Dea,th AT'• •.•/.( 19........
•
Age �—.r`3' Yeas Mon s,.... .Days �'" Birthplace . .. . . . .... 4_
Cause of Death........ .. ..... . .. .k'.rir..��c.l)j
Certificate was signed• M.D.
Address .. .. �.. .. ,...........
. .. . .... ..
Place of Burial (or Removal) .... . . .... �...... .
(If body is to be tempor '1 held„.fili ND r)
Cemetery �4 � [- .. . . ....... .... Da e of Burial 1/.3 19..,..r�
(If body is to be temporarily held,fill, space later)
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 ac pted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, o e basis thereof eo€ I HEREBY GRA T A PERMIT `�7 � . ..1...
to %rzr.,....�v 17G. � . rti , i
me)
the �i .— (Address)to hold temporarily and .. . the body.
(Undertake r rsopn having charge of corpse) (Inter feinov or ot$frwi dispose of [state how])
Dated .//.1.... 19 - s.; (Signed)6- -t, ::.i...r
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (*abject 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
1 Date of '' was ? 19✓
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
(Signed) Le(JI �I
(Paraso to charge)
Address
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fran 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 cords
"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 reLai,ive 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.