Rainville, Francis Form VB.Si. NEW YORK STATE DEPARTMENT OF -HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
to 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 CERTIFICA�OF/
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No—.:.O
Village
Dist. No ` 4' (Cotmty..-6t; C,L-z.`'--/, fl ,--- or City �f . ........
(If city, giv street address)
Name of deceased ,� -r�->z�-; - Veteran
Single, married, widowed,
(If vote live name of War)
Sex Color or divorced (wnte the word) Date of Death_... •-"-z'.{ 1 19W
Age Ye�ars t Months Da irthplace c` �"�/' 4.....-. .a
Cause of Death `?-t- ... .... .
Certificate was signed by...M .. �->' M.D.
Address . 4 7
Place of Burial (or Removal) �--IA
(If body le to be m rar11 fi�eeld, 11 in ace later)Cemetery ' L ... . Date of •rial -4-c.i )..3-r- 19....6
(If body is to be temporarily held, in apace later)
Thq Certificate of Death c taining 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
Numbeerj_�on the..bas' thereof EREBY GRANT A PERMIT
to l /`�` ».1.. ...—?:i�t_ 'Y`' -I-- j�t�'�✓ r " ...
/ (N ) Address)
J
the S�� -� to hold tempora ' and the b dy.
(Und taker or person having charge comae) (Inter,re ove,or of se aye a of[state how])
Dated �-c..,...%.4... 19... .)----- (Signed) . ..
Local esutrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body o any past of the (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
INDORSEMENT OF SE X'1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was / 2- // 19 Ce
(Interment or Cress tion)
•
(Nsse of Ce tery, Crematorium, etc.)
4/0
LA Creeis
Section A Lot No. 1 3 Grave No.
(Signed)(/et. ) . 6 (c _1)2?"4„,_
(Person in charAddress - a .. �v 0 O
pgZ
Person in charge must return thi 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 OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.