Loading...
Charlebois, Alcide NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT gar 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. Village Re red . .. rr l �� ^ Town, _,, // Dist. No. J 1 o ty. `" �' ' or iy eS�.C�f... wit y r y (If i , give street addrEss) Name of deceased . .. .... �' /�'4 J Veteran ...t , 7 (If veteran, give name of War) t Single, arried, widowed, 22'/I'2,,,U i'. c�Sex ,-,.. .I. . Date of Dearly- S 19 ./�� Age Ye .. /�lo�~nqt�hl�s .Da Birthplace Cause of Death V,,r.,!45..:.. . .-.): c..- Certificate was signed ) - - ._ .:` .. --►"'� . :... . M.D. Address ...... 424e2 /-,,,;%' Place of Buri (or Rem al `� _ Qy .. .. .. (If body is to mporar h f in space later --}-- Cemete ... .,,4,1'.� Date of Burial lG' 197 (If body i e temporarily h d, fill in space lacer) The CE TIIICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination,the same 4p ea ing to be COMPLETE, CORRECT, AND SAT FACTORY AS REQUIRED BY LAW, I have accepted the same for registra- tion, hay ecorded it in my Local Record wi the abov stated Regist r d Number, an n the basis thereof I HEREBY GRANT A PERMIT 1 di ame) ( a�ress the ':.'.(._1 to hold temporarily and \ the body (Un erta er or persan rig charge of co e) (Int emove, ther�/l di� `""'Yf (state how)) Dated — 192 (Signed) ,(,(LOB ocal Registrar This Permit is sufficient for the Removal (and Interment or Cremation)of a body to a 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. FOtItm VS. 61. (11EV. 6/63) (A2-248) ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON WHICH INTERMENTS OR CREMATIONS ARE MADE Date of STIte-r7-77-amiwas -- /© 19 (Interment or Crem ion) c : CC , (4t4 (Name of mecery, Crematorium, etc.) V Section Lot No. g - Grave No. c r J ' (Signed) ((Person in Charge) Address6. LC /a) 440 AIdt /V /• Person in charge must return this Permit to the Registrar of his District within SEVEN (7)_DAYS from above date. f no person is in charge, the FUNERAL DIRECTOR or UNR- TAKER MUST SIGN ABOVE STATEMENT, write across tive face of the Permit the words "No person in charge," apt],-'` FILE PERMIT WITHIN THREE (3) DAYS with the Regi tsar 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.