Blanchard, George Form VS.61 NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit tan 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 1NK.. Town Registered No.......06. 2
-- Village 6
Dist. Noi..‘;44...Couray.......Zi.-/.4f -.....6. ....4.i.ce...- or City ....---- .1--"...--44, (..„ . .224.....22...:. ....
(If city, give street atiless) ,
Name of deceased ..--- --14---41.(---' ...,1 4---e:4"--) - .-(-4.. ...e.,- - -‘,...„,*(.. Veteran
4 Single/married, 'widowed, ---- (If Mersa. give gsmce7r:!,War)
Sex) 4-," Color. 4.1&o' r divorced (wn
tethe word).. .. . Date of Death.. ....... '
Age.. t Years ,." Months Days Birthplace ---44-1-t.,..4„,
Cause of eath.....„..,<C444../
/4/. .7-- z.,„6.,
Certificate was signed by.... ...(4-./..e..,f....6...7.- M.D.
Address 4. .--A.z. Zet-e4, .4, '-il
Place of Burial (or Removal) 1-----4-4-.‘zrag.._./ y .....kx...z.e......06.
(If body is to p arily held,fillAn'pace later) ' ,
Date of Burial.. ./Lf./' ,./.d 194/
(If body is to be temporarily held,fill in space later)
Thg 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 ,,_e_.!istered
Numberjouyi on the basis 'fnITEREBY GRANT A PERMIT r-
to.,.... ..i...../.. 1 .ac)...e::07, . .......... (-
... _,. "
. .. .es?.......,,, ...d..„24 ...--'2- j .
the &?4,..7wd
--4 .:"K--(,,-/d.le-laanie,kej,/ hold temporarily and t ody.
(1249ertalter or person charge of corpse) ,flpsterAre9ove,e,tesserjr&Isom of[state bow])
Dated .4 /- .d' 19. .:// (Signed) 4:-....- .....r.
Local egirtrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Siam (smbject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSE ENT OF SEXTON OR PERSON IN CHARGE OF
PR 2dI SES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date ' ( i was '-- (I19 l
(Interment or Cre tion)
Y4:(-,e c-.- ) 6(1:7',.'---1::6 .
(NAme of Cemetery, Crematorium, etc.)
''' ;24
Section [L i% C"'T�ot No. .2A Grave No.
(Signed) 2! '-1---, �-Z -
(reran in charge)
Address ) C-- , -(1Z
Person in charge Heist return this Pem/ t-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 OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.