LaPoint, Emily Form vs.SI. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ttar 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 CERTIFIATE OF
DEATH, LEGIBLY WRITTEN DURABLE BLACK INK. Town Registered No.._....� _.__
Villagr
Dist. No. County... .a..ili).�Irlr.�.. or-Citi-
(If e'ty, gi st t address)
Name of deceased ,,.�.,Nl !.f!— . —'`,.. ..•Tie. /.,•47 Veteran
�` (( Single, iliarried, widowed, r4L) et slue name of War)
Sex. .. �.... .t` olds&!. . .or divorced (wnte the word) 44�rr &...Date of Death 19L
Age ^ U Years {t s o s. ». B' 1 ce -
Cause of Death t -cx---�' -... rr+:^F,�.l� t ar,.i.r. .�.��" .•••�l�K.:'`La°[{
Certificate was t by [!�L ..emcx-- ._ . M.D.
Address. ... :'):: -..�. ,„�.. �r �
Place of Burial (or :emoval ...,e.
(If body 1s tobe`temp V fl la
Cemetery.l .?.:?: w. . . . . A Date of Burial �/ 719c.a
(If body Is to a temporarily held,fill in space later)
Thu 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 hay ccepted the same for r .stration, have recorded it in my L I Record with the above stated Registered
Nu n t
b is the I H4EBY GRANT A FERMI -2;74-L
ame) 4ress)
the to hold tempora ' nd e body.
(U, ertaker or rson havin char corpse) (Inter,remo the se nose of[state how
.....e
Dated . .....I,.... 19 (Signed) . .. . ... .. .-.4.€ ^,^..
al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) ofody to any part of the State (*object 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
PREMI SES ON WHICH INTERMTS OR CREMATIONS
ARE MADE
Date of,'/G �e.-4 -.l�' was,k�/ J�-3.17 19 ‘ 3
(Interment or Crematiany
<-1/,...e<-'4-/--,/-1,t- ' el--.-0 7C.' '. e.., (:___„,47,,,,_24_ __,
'1/4:4:71;( '(Name of Cemetery, Crematorium, etc.) /
Section ,�� Lot No. Grave No.
(Signed) "-X>4—•'9‘<..__ C _c'`Z--,-elCl'
(Person in charge)
Address L' c, C y (' k'i--� -t:..,_ 3C�`-.
Person charge must return this Per!iit 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 OFrENSE.
The law will be enforced. Local Registrars are re—
quired, under penalty, to report violations thereof.