Normandin, Alida Form vs.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed only by the Local Registrar (Deputy or subregietrar) 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. ,T.own Registered No. .._...._....._._
Village
Dist. No /Q/ County...... - or City�� �/ �`a' (if city,etgive street address)
Name of deceased County .....
Veteran
.-co--Single, married, widowed, ([f veteran, give name of War)
Sex i Color or divorced (write the word) — Date of each.. . ' 7 19 C,2----
Age ' ..V Years Months ....:.- Day i p ace
Cause of�Death ......... .. ...
Certificate was signed by r-�%' M.D.
Address .. ......
--,,,,-
Place of Burial (or Removal)... . .. .
(If body Is to be temporarily held,ft 1 spac at ) 7i �,,, i /v.. ��
Cemetery Date of Burial • `�/ 1
(If body Is to be temporarily hel ,ft 1 in space late
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 cord with the above stated Registered
Num and the basis thereouAH,E'REBY RANT A PERMIT ��Jt
(Name) (Address)
the to hold temporarily and the body.
(II ker or rso having charge corpse) re or of r�ae di ose [state w])
Dated �'� 19 �' (Signed).. ... .. �/7-
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a bod o any past of the State Ora ject 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 was ' v'" /Z 19 4 2 -
(Interment or Cremation)
r /
(Kama of Carnet y, Crematorium, etc.)
pp�p��pa. w �S a 7 d o
v4M'✓ Section Lot No. ►3 !!ll i Grave No.
(Signed) . (/ a•
/���L� 4--'01e.A°61
((parson in charge)
`1
Address P-e-.4-A-AlJ :1"..t.6
4//7"
•
Person in charge mast 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-
VENT, 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.