Casavant, Herbert Form vs.al NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ur 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. Town Registered No—e.e..i.g..........
or
ricItgety
Dist. No..i.a72.4.-County. ... .. ..<114-: .14"..,. '11"1---
(If city, street address)
Name of deceased d4/;-41-.4-'4-e" selielar-fieit,g Veteran
Single, married, widowed, .
r divorced (write the word) Date of Death
veteran, give name of War)
Age A, Leiali.:24.44404.4Mo t1.i..s i 2.74s0...„.._„.. Birthplace. ... . ........ . .... ................
Cause of Death •Arire"-et,. —.el•e-71,47--'"•194r.4•1Fe .. •
Certificate was sign d by Z,1:"-edr... M.D.
Address... . ' 4., ./. . :•d ?77 '
Place of Burial (or Removal)
(If body Is to be te0.22rar1ly held,fill in space later)
Cemetery ...4../ .44.1&3.enr.i.4.4.- Date of Burial C-gl'ela-1 7 19.L.I.
(If body is to be temporarily eld,fill in 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 above stated Registered
Num a_arcr.fa4„....d on the hOis thereof I HEREBY GRANT A PERMIT - 1
"
„..1...-_,
ilNaine)
the ,.......)....A/1,1---<---V-2-1.-' "-g- to hold temporarily and the body.
(Undertaker r person hayilig chargva corpse) (Inre2over othe se d4„,)ostatate howD
Dated 2-3 19 0/ (Signed)
ocal egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (eubject 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 SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of a, nn"-z ' was C ' / . ,� 19 Co I
(Interment or Cremation)
___L;14/ 6,___.,...94 . —,,,-,.....o.—e-<..--;r
(Name of metery, Crematorium, etc.)
Section Cr.�- K i =. Lot No. Grave No. "/L/ 0
(Signed) 4 " � /' - "Cn Pa-u-i2„-
6_4,...._,_
(Person in charge)
Address /CP (; rG4 )( G Q o
Person in charge waist 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 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 OFP1NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.