Blondin, Moses Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
•
zr 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 -flown Registered No.......2...C.'1'. ,-,5-
-Village
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Dist No..-t' Z'Ci' .County...k.--) .!;-..4:-.-.-1---E--- or City _ ---:?../ --0-2----,
(If city, toe street adaress)
,y-r7 -
Name of deceased "---;/.-4-2--e -1
-T., .------r ..,..L.--to--,-__/(-;____., Veteran
pr
, i Single, married, widowed, v-, (If aeran, give name of War)/ cy-Sex --c,
/xlv Color ' or divorced (write the word) '' -14-4---t--7"--4 4'4.zbate of Death '- -(.-.\--‘'--,-.;--- .).
19.a..yi
Age (...:' Years. Months ,,.......—.pays ,.. Birthplace
Cause of Death ev...2.-7--r-r. --c-A.- ----:'/-2---._<_, ( _'.0.„.,,____.,-:,....1.___,,__.,....__.(,._ ,vc, ,‘..,./___,e,
....--). , GI• f SV /
Certificate was signed by ir, L.A._) /72::-t,c_.--,-
0: " / v,
1. M.D.
Address ,. ----(-.) —- ".•4' Ct--- ket/Place of Burial (or Removal) --"" - 2 - •-'i =.7--e- ----..-- :4,--s z.,.. :_-____,4
(If body is to be aIrrarily_held.till 1,41,Ze.:later)
/2 .Z •
Cemeteryit. V.,. DateCre Burial --C .--e-c....- ..Z. / 19
(If body Is to be temporar1-171reidy-11 in spaee'-icte7)"-.."---14"
The Certificate of Death ontaining the above stated particulars, having 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 recorded it in my Local Record with the above,s ted 11,gis
Number, 9,n the basis thereof I HEREBY SiRANT A PERMIT k .
_.. .„
to.. - -1 I-- "71- - - );l ••. v.--x -.-..- ..._____.... ,,,____.- -,, --0 (..,?... _.7thji- l
7 7(Napse) _r_lz_z . (Address) L "---‘ z •
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the 4- -4- v.....-ak.c.,<---'-'t f-.4:e.c.... to hold tempor ' y and • • ,A---,.-, .. dy.
(IIitlertaker or person kaving charge otrpse) / (Inter,remoy,e,or thywiM4Jsno. of howl),
19 /._:) (Signed)
._ ,
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any past of the State (asbject to local
cemetery or other regulations),unless removal is by common carrier,in which ase a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was /V I/ 19 ti7
(Interment or Cremation)
(Name of Ceme y, Crematorium, etc.)
SLC
Section o. ot:..'`./9 Grave/et-W�`.J.
/1V(Signed) iL/ ��./arge) �ivC
Person in charge)
( 8 )
Address -( AYcl
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 DIRECTOF or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permitithe 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 OF I.NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.