Lemery, Charles NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ram` 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 ERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Ze/c..,,A1/141h1J
• Town, Vill a R��e/�'stere No. JDist. No .(16%' 11 .or City..... (If cat ,>
f (If cit '•e street address)
1
Name of deceased ....��. . 1.. //' Veteran �C
(If veteran, give name of War)
Single, married, widowed, ,�,p�
Sex ' 1 ,•, or divorced (write the word)�.. �� Date of DeaCt n /? 19 ...7...�/..
Age �T Y s ......Months D s - Birthplace... ...
Cause of Death /4Certificate was signed by ...,/.4.4".)24,144
/! M.D.
Address rt_ c%� ,,, -
Place of B (or Re ov 10
(If body is t•�• l tempor r ly el (i •�n space l to
Cemete. lir /, Date of Burial ? ( 19 7%/
(If body is to he temporari y eld, fill in space later)
The C TIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same earing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, a recorded it in my Local Record •ith th above stated Regist end Number, the basis thereof I HEREBY GRANT A
PER /
to .... .... . .' ` 41
E(Nart16) 1 (. N aiessS....... i
the ..... to hold temporarily and It,., the body
( ndertaker or on having charge of cow e) (I ' __ v of s ose of (state how))
Dated ,1?.� 19 Lr (Signed) /
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the 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.
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 19 7
(Interment or Crematio
I+ QIAobnwg.
(Name of Cemet , Crematorium, etc.)
Section Cam. &dr Lot No. 3 Grave No. 7
(Signed)
(Person in Charge)
Address 3 errzt-60 4t1 21L 9- Ai I.
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 THEE (3) DAYS with the Registrar
of District in which cemete 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 required, under
penalty, to report violations thereof.