De Lisle, William NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
•
` 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. SOS "
Town, Villa a Re 'stered No.
Dist. No., � f ' County
...��.... . . . or City g .... �
///'�:�:�" 6�� �„ an city. give street address)
Name of deceased L% t'"rr- Veteran
(If veteran, give name of War)
Single, married, widowed, g/
Sex 7� . or divorced (write the word) . ... ... Date of Death ......l..l�L 19 7.i4......
Age 90 Y rs onths Days Birthplace..2'1.,...r
Cause of Death `�zr e-ems ,sue .
Certificate was signed by ... (,/.. - M.D.
Address .,.�z .e bi .j.�i: _, 'z c7
Place of Burial (or Removal) m, -9 77
(If body is to be temporarily he ¢, �Il n pa later) -
Cemetery �/.1�1 - ' Date of Burial 9//4/ 19 7
(If body is to he temporarily eld, fill i 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, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, hav recorded it in my Local Record with the above stated Registers Number, and on�the basis thereof I HEREBY GRANT A
PERMI - • /� �-� ' 7 Gba
(Name) ( �resfs}���
theto
to hold temporarily and the body
(Undertaker or rson having charge of.,c rpse) r, remove, or of rwise ispose of (state how))
Dated / 19/1 (Signed)
4.0c istFar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body t ny 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 P -' 4 was • " / 19 7r
(Interment or Cremat' n)
ie,
(Name of Cemet ry, Crematorium, etc.)
Section z 'oZ✓1- Lot No. 1 Grave No. 7
(Signed) / ilk-'4-L '_
" rson in Charge)
Address 3C �l�` It Al/ /.
Person in charge must return this Permit to the Regist r
of his District within SEVEN (7) DAYS from above date.
person is in charge, the FUNERAL DIRECTOR or UNDE
TAKER MUST SIGN ABOVE STATEMENT, write across t
face of the Permit the words "No person in charge," ,a
FILE PERMIT WITHIN THREE,(3) DAYS with the Regis,
of District in which cemetery is located. '
SEXTONS, FUNERAL DIRECTORS and UNDERTAKE
violating the law relative to the return of permits are liable 4
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.