La Fountain, Adolphur NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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.
� � Town, Village
.St.,,
Registered No. Ira..--aIra..--aDist. No... .b..1...... County �,..J. or City
(If city, give street address)
Name of deceased (.. Q. C.r. .` -,N.Veteran ._. ._
`_• (If veteran, give name of War)
Single, married, widowed,
Sex . -St or divorced (write the word) Date of Death .),.....:\ 1915...
Age 1.1 Years , Months Days Birthplace �,5 > S \
Cause of Death .... ... ��,.1,..-i-'........ •••••2 �.3.3.,.4..
Certificate was signed by M.D.
R �Address � .L `�� ^�V
Place of Burial (or Removal)) ,... . . Q. sZ.. .q
(If body is to be temporaril id, fill in space
Cemetery � .9-� Date of Burial "14 19'7°
(If body is to he temporarily he in 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 recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
P fi13:1 � 4N1 (� q- ( � r
to '�`4. C ....s&- �-L \ v,✓Sf-,,NSL Vi , J l.] ..4 .c,s_
(Name) ( a. teas
the t - to hold temporarily and ...: 4 N _ the body
(Undertaker or person aving charge of core) (Inte mov , _^per 'p!ltSh� (state how))
Dated N"\SN.� -C 3 19 "7 (Signed)
Locr..Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of t.. 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.
FORM VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
f
Date of jVi was 2 /19 vC
(Interment or Gerrnert4- )---_‘4C-1-721-e.„.e k:----r----i---Z-1/4------/
(Name of Cemetery, Cronafreerit--
441 , ,k-
Section Lot No. 0 /Grave No. /
( io
(Signe. IA a v ) ` ',,
(Person in Charge)
Address ,eriz:///',,,,&*(; /el:
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 UIWER-
TAKER MUST SIGN ABOVE STATEMENT, write acrofisihe
face of the Permit the words "No person in charge," V9ti
FILE PERMIT WITHIN THREE (3) DAYS with the Registrrar
of District in which cemetery is located. o
i/.
SEXTONS, FUNERAL DIRECTORS and UNDERTAICERS
violating the law relative to the return of permits are lae to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.4The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.