Terriault, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. p/�' �6
S6 r Town, Vill 2G "'Z stered No.
Dist. No. ... o .. County... CteletPl.Y�_ , or City
p ,.
(If city,give ttrr/ee/sJlb,Bd`res
Name of deceased Veteran � 0...../......4—
` (If veteran, give name of War)
Single, married, widowed,
Sex or divorced (write the word) ... .CU Date of Death s-` 19 .2 /
Age ?tears. Months }.. Days = Birthplace. -
Cause of Death . ... .... k
Certificate was signed by M.D.
Address .. .. 0 �
Place of Buri (or Remov 1
(If body is to b t mporari , (' in space 1. r,
Cemetery . . L Date of Burial S` /S 19 ,�Cj
(If body is tempora 'ly hel , fil in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORR CT, AND SATISFACTORY AS REQUI ED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Reco with the above stated Regi red N _ ber, and on th basis thereof I HEREBY GRANT A
PE I•I IP
//
to a1�—orl ,n A (N f... 40 ddress?-&te-7
(Name) /
the . .. .. to hold temporarily and the body
( n ertakerorS 1 `/person aving charge of co sh) ( r, removerwt o dispose of (state how))
l
Dated (Signed) ...
Locr.Regigtrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t..e 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.
FO.I2M 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 aS-rrYttpt was 19 "23
(Interment or Cremati /
(Name of Cemet ry, Crematorium, etc.)
Section covr Lot No. I I Grave No. e2
(Signed)
(Person in Charge)
n `
Address 3 ���� L (Yit i A/X
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 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 retumof 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.