Lefebre, Emma Form vS.U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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 ram" - Registered No.._....3�..
Village CJ ,
Dist. No ' L.'''/ County C-6.'Cz e- or City =";�C e�� �, C'
v (If city, give street address)
Name of deceased .�ti G" — Veteran —
IIYaI rled widowed, (If veteran, give name of War)
Single, / (.3 19 "2—
Sex .Color i'v or divorced (write the word) l �t-� � Date of Death. ..
Age lk Year y /Months Days • Birthplace 7' L£ti"'"'"{'-
Cause of Death 4wL( Cer L'CE-4--ce4. lr: e -zE�t,-`� �
Certificate was signed bye ,3 � M.D.
Address / 35 l" = -, �)' )-aJ )
7,
Place of Burial (or Removal) 4L C��� ��-'�-��"�--
(If body is to be temporgrily held,fill fnfpace later) ,, l
Cemetery ' (1-�4i.'rd 4,/,c_ ^z.A."('r'1-c" )'Z C1 Date of Burial...,. 4 6 19 L'
(If body L to be temporarily held, 1 in space later) ,
The Certificate of Death containing the above stated particulars, having been pr ented 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
Number, and on the blasis thereof I HEREBY GRANT A PERMIT / ( ,
to +.6 t!C k`C't,S, ...J.:la.te:I :rr(:4:iw"��`'`t— / Y',r�e�'7 Ci�
� ) {Sgdress�.,__._
the L ‹.,.---- 'k c���G`-4 � to hold temporarily and ./..���`r t��" the body.
(Uptaker or person having charge of corpse) ove,or(Inter,rem otheraellse disco a of[state bow])
Dated...,. ..t 5 19�' (Signed) � .
al Res'ati'r
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the 6litate (eabject 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 19 6
(Interment or Cremation)
(Name o Cemetery, Crematorium, etc.)
0 hi)
Ro if/ 5
Section Lot No .} t Grave No.
(Signed) �'2! -/ 'r ^' C /J
(Perepin charge)
Address V
Person in charge must return this Permit to f1/
//
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.