LaPier, Lawrence Form VS.el- NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
' This Permit can ba 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 Town Registered No._....L...7
j Village
Dist. No .S C't County.. ..y� »1�..21�ti` or City . ..ti
- (If city, give street address)
Name , -O C Veteran - -T •
of deceased G.:...:,.�7 :1 .1... �/ .
Single, married, widowed, -� (II ♦eteran, give name of Wax)
Sex y:... Color / / or divorced (write the word) �.J.a ''"-`' -i Date of De th r, 4 "� 9 /
Age ' Year .j Months Days Birthplace .:0 ..
Cause of Death �r �-r- e 7
Certificate was signed by :.. ..... ?1 "-' M.D.
Address c-77.C'e%ri.
Place of Burial (or Removal) 2!?�...`j st -046...rt .
(If body Is to be temp•'. .ly h Q,fill, ace later) �/ /
Cemetery . `, .• 4 n`' z``� -k2- Date of Burial �� c 7 19.w./..
(If body I to be temporarily held, 11 In apace later)
The:Certificate of Death containing 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 stated Registered
Number,- on the basis 3 E EBY GRANT A PERMIT / /�
to s ` 'a= `r�-� �' ''- ) -/%
(Name // (Address)
the t ,4„. I C-x to hold temporarily and ._. jj the body.
(Undertakerpr rso vi charge of corpse) (Int ,remove,or otJferwise dispose of (state bow))
Dated l..r� k 19.P0./, (Signed) t'`�-'''s--------
Local Reglatrar
This Permit is sufficient for the Removal (and Interment or Cremation) of • hod to any past of the 'fate (subject to local
cemetery or other regulations),unless removal Is by common carrier, in which cask a T anait Permit (VS No. 62) is required.
ENDORSEMENT OF SN'X`lUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTENTS OR CREMATIONS
ARE MADE
Date of •`' was /2 f J L 7 19- 1
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
61P MA- I)
Section / Lot No. `+)6 Grave No.
(Signed) /I -1 ., �';�, � �✓'�^ ��J.�l�t�
(Perann in charge)
4
Address ;�` � ✓� rX n c
Person in charge must return this ermit 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 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 THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.