Lasher, Lena 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.
4ex...iLU
��/ / / Town, Village ngi d o.
Dist. No. (0.7 ounty (.�G:_/>/11Ge or City (If city,
give street addres(b)
Name of deceased --4-', li=-s2 o4 Veteran .
(If veteran, give name of War)
Single, married, widowed, /'A
Sex/J2% or divorced (write the word) .l� k-4''�- Date of Death ..4a(w � 76 19 .71
Age ,..a Y Mo hs ...... .......... Days Birthplace ,, 1.. ....;
Cause of Death . .
Certificate was signed b p .. .. M.D.
Address ,.?. :�.. :�.�L. / , G 0.�� .. ..
Place of Burial (or emoval) .. .
(If body is to be tern rarily held, (,. ace a
Cemetery / Sl. Date of Burial „ /,.5 191 '
(If body is to he temporar" tly held, fill in space 1 ter
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same appear g to be COMPLET CORRECT, A.D SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have'orded it in my Loc 1 Record with e above stated egistered Number don th asis thereof I HEREBY GRANT A
PERMIT
7
to , , ` Ni �. ��
., ii Name J(-- (Address)
the to hold tempo arily and J the body
(Underta er%r person aving charge of co`r se ; I ter, remove, or otherwise dispose of (state how))
Dated ii ' 7.2- 19 (Signed) L
This Permit is sufficient for the Removal (and Interment or Cremation)of a body any part of the State subject to local cemetery or
other regulations), unless removal is by common carrier, in which case a Transit P rmit(VS No. 62) is required.
FOItMT VS. 61. (RP:V. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of - " was 'C-'/i I9,S
(Interment or Cry
(Name of Cemetery, ' matori m —
Section 3.'3 Lot No. I.. No. I
(Sign
(Person in Charge)
Address
Person in charge must return this Permit to the Regi trp
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 th "'
face of the Permit the words "No person in charge," ",f+
FILE PERMIT WITHIN THREE (3) DAYS with the Registra
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.