Geroux, Mary Vona vR a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
V6lage, or City) in which the death occurred Am the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK C INK.. Town Registered No._..... ....
c.7416—
Dist. No..� :(../County. ..y F - ��,,,'.'.iie!! -. V co .''' .. Q
i , or
,. - (If city, give street address)
P ' -- lam" l„y
Name of deceased....1 .... ...5.� +� Veteran "u-a
-, ' 4 (If veteran, give name of War)
j,,,- ngle, married,widow..,
Sex..\. Color /I or divorced (wri the • - ,6)..,Iv . .. Date of eath ‘ 19.. -„F
Age X-3..Year Months ays Birthplace 747A
Cause of Death. ... - ,,. .... ..R
Certificate was signed by.. `` M.D.
-
Address. ..l ... ... •. ..
Place of Burial (or Removal •
/)
(If body Is to be temp r rily h r op ife later)
19. . �
Cemetery.. Da Burial. /
(If body is to be temporarily held, in space liter)
The Certificate of Death c ntaining the above stated particulra7rs, hiving been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND+SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have r ded it in my cal Record with the above stated Registered
Nu on the basis fylpt T Zit
the 02 ..... to,hoii ... tem _ ly ,.... the body.
(Undertaker or person having charge ) ► J (luster,remo ,or o i`to e o state bow])
Dated - 7 19•. ' (Sig led /2,r---- Z7//
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) 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.
INDORSEMENT OF SEXION OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Dated was '" /4 19v j�j
(In teent or Cremeti n) /rm
a.
iite_y„.... ...v.,
(Name o! metery, Crematorium, etc.)
Section of No. id Grave No. il
OARP&_44,1.4zi,
(Signed)
(Person in charge)
{
Address N'Ar-11:4-1-1/---fre Nr411"--.
eglLie•-4, �i��A- 19 ' X. 7
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 UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face ofti Permit the words
"No person in charge," and Msud
WITHIN THREE
(3) DAYS with the Registrar of Ditrict 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 LE$S THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OIFI.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.
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