LaPier, Emma Farm vs.GI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tir This Permit ran be signed only by the Local Registrar (Deputy or subregiatrar) 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._... ._ . ......__
Village
Dist. No County.....,,1.... .4,« e.-,--- or City -&. •7 -{ •
(If city, give street address)
Name of deceased =''-- .Q ...r veteran
j Single, married, widowed, dd 77 (If veteran, give n e of War)
Sex Color / ' or divorced (wnte the word)....,/.f!,/l^YY µ f Date of Death -S 2-y 19. <
Age :....Years Months...... .7.....»...Days . Birthplace 7.. 4.- "Ary
Cause of Death Uz i L ,,
Certificate was signed by '/1 �`-' = t M.D.
Address ;.,ter`:............ ‘. a. �T /J
Place of Burial (or Removal) ;... :. ,-'Z s, � r t ,/
(If body is to be temp, ly hel d,, 1 apace later)
Cemetery Gt c'� )-- - -7 C,ft s:/.-.) Date of Burial 19
(If body is to be temporarily held,fill space 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 e]]above stated Registered
Number,
�and
� on the basis thereof I HEREBY 7NT A PERMIT � ,. 7
to •.•d/•. /� .- .. 1 Cwe. :?..G.. .... .. C- 9 22/
(N A — (Address)
the :.h to hold temporarily and u the body.
(Undertaker or reoy haying charge of corpse) (Inter,re�ov�,9ierwise dispose of[state how])
Dated j ` 19...G;,./ (Signed) ,f'��``
Local Registrar
This Permit s sufficient for the Removal (and Interment or Cremation) of a body to any past 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.
ENDORSEMENT OF SEXIUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTEB?{ENTS OR CREMATIONS
ARE MADE
i
Date o .X. '' i ,..r-was ri/1 __t 19 6/
(Interment or Cremation)
_,rb4'-. .-((1_ .uo .,ry,.,.4L.
(Name of ry, Crematorium, etc.)
RaW E
Section / Lot No. Grave No.
(Signed) 9/(Z-2-fp . Gt:%in charge)
Address 6C)
) -31/14:- , --, A,IL-t. , >? .
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 UNDFRTAKFR 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.