La Point, Silva NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
far This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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. t
'• Town, Vill �gis�d NoQDist. No.S E� 4( i Imy....11..) ( '►^' ... ..or ity .1'1/7... ��f�' 'p E (If city ive veer a )
Name of deceased �/. .. 'lam ✓ 1 ..„...... u Veteran i.�
(If veteran, give name of War)
Singlejmarried, widowed, 3 ��
Sex or dibdreed (write the word) Date of Death 19 ..iy
Age S Yea ...Months Days Birthplace.. .... i
Cause of Death ' ✓
Certificate was signed by ... .......GL &. ' I M.D.
Address � 0• ..;1-,a-... c... .... ?e u"/ . ,
Place of Buri or Remo al ... ,:..„,, ..... .. _, ,
(If body is to b mporar' y h�d space lat /
Cemete ,.._.. �`.- rv24(-- : rj,,.. Date of Burial _.�, CP 19
(If body is to e tempor rtly he d, fill in space later) f
The CE TIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same aring to be COMPLETE, CORRECT, AND TISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ha rec rded it in my Local Record •ith the ove stated Registered b , an. on the sis thereof I HEREBY GRANT A
PERMI V / g �/�� c-
to
(Na m ) j , % ( ress ,
the .... . .. t,.i to hold temporarily and the body
(Undertaker per o having charge of corp1s,e) ( nter, remove, or otherwise dispose of (state how))
Dated .. Js 19 ...V 7 (Signed)
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t ny part of t..z State (subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit Per it(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 a")*O:rrAite. was ' 19--7V
(Interment or Cremation)
e'f r A Aitia-v•3 ee,rtlX.f,
(Name of Cemer ry, Crematorium, etc.)
Section IT/6) r, Lot No. ` 6 Grave No. /
(Signed)
(H'erson in Charge)
Address ?6 �"'�f A "�`� “
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 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.