Briere, Estella 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,
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.
7
JTown, Village egiste d No.
Dist. No. .; County "t.,r...��„ �) or City - V
�� f.,"
(If city, give street address)
Name of deceased V O�f�ar klZ-Le/L-Q-ji eran
(If veteran, give name of War)
Single, married, widowed,
Sex ,,. or divorced (write the word)(2�L4114. t,� Date of Death ^J.7/l� 19 ��„
Age .5 .c.' Years Mont s . ....... Days • Birthplace - �f ;
Cause of Death , ..e...G !;Y..1.,L.,Ge......
Certificate was signed by V. r M.D.
Address ! ,*`'/ , �G....,.... Ca- 1 .
Place of Burial (or Removal c�--
(If body is to be temporarily h d (i spat ater ,.�
Cemetery .,j/L„+4-Eh.' Date of Burial „�,. „�v 19 7
(If body is to he tempo ri y held, 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, have ecorded it in mLocal Recor with the above stated Re ' ered Number, and on the sis th of I HE EBY GRANT A
PERMIT _ �,/
to :l f.t a 't — `
(Nmlr!/ (Adaiess)
the ..... a-,.... to hold temporarily e body
( ertaker or person h_av n_g charge of cor se) ter, rem or erw a dispose o (state how))
Dated c5 / 19 .. 7 (Signed)
Locr .Regigrr
This Permit is sufficient for the Removal (and Interment or Cremation)of a body o any part of t..c State (subject to local cemetery or
other regulations), unless removal is by common currier, in which case a Transit Permit (VS No. 62) is required.
FORM VS. 61. (RH:V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
•
Date of was i , 197V
(Interment or Cremation)
/4&.
le)11 en.",11
(Name of Cemet ry, Crematorium, etc.)
Section�� B Lot No. Grave No. '
(Signed)
(Person in Charge)
Address 3 S 7 " I) /e ? j 4) )/.
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
TNAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.