Duclos, Walter NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rip- This Permit can be signed only by the Local Registrar (Deputy cc 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.
Town, Vill Re/' ere o. ..., .1.�
Dist. No.,? .C)/ County........ 0'U .. or City 1 = 'ri.,2 ('J`7
(If ci , giv st eet dress)
Name of deceased C�1 Veteran .. ....��
(If veteran, give name of War)
Single, married, widowed, / J,
Sex or divorced (write the word .. ...... . ........ .... . Date of Death �"/ 19 �7
Age Years.. .... Months ys - Birthplace......
„,
Cause of Death
Certificate was signed by ... . � k..) . ... ,
Address - ... ��1� 7 `�`'� � M.D.
L�,
Place of Buri 1 or Remo al ....
(If body is to mporari}y d ( n space ate
Cemetery _. ( .,,,.., yr Date of Burial q— l 19'21/
(If body is to a temporarily he d, fill ins ace later
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same pearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ve recorded it in my Local Recur with the bove stated Regi red Number nd on the basis thereof I HEREBY GRANT A
PER& T . Gc-tg
(Nam ) i (AZ)
the . .. . . --J to hold temporarily and . 'rt the body
(Undertaker or/pferson having charge of coyp te) er, remove, or otherwt a dispose of (state how))
Dated " /..0 19 l i (Signed)
fft
Locherwi ee dis
•
This Permit is sufficient for the Removal (and Interment or Cremation)of a body any part of t..s 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 ofA was (,K -4 I/ 191_4_
(Interment or Cremation)
tQ CO-4111 1Utr
(Name of Cemetery, Crematorium, etc.) d
Section t-7)87A) /C Lot No. / Grave No. 1-71
04/142
(Person in/Charge)
Jakkives-
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.