Hubert, Louis mnr.R�; Is.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
' This Permit can be signed only by the Local Regis r (Deputy or ubregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after th G and acce• •ce of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTENIN,��'lDURABLE BLA K . To Registered No._
Dist. No � ounty...Y/C.1T....Q . \` • ..IC2o -e. a4 -c. .a.0..p.
(If city, give street addre,)
rr T' ., �-
Name of deceased 4. (a.J..s. 4 -...Y...... ...I Veteran
(If veteran, give name of War)
Sin: marn ido 'A' •
Sex... Color or ,.ivorced ; te word).4'�/ AO.1C.?/rD Date of Death..a " -) 19:� -"
Age 8' Years .' •, a s ...........Days Birthplace
Cause of Death < ......
Certificate was signed by���� M.D.
A
dre
Place ofdBuri 1 or Re ovLl Q. h/ a 2- d Cc 4)-e At S QQ I. ,'
(If body is t ,be m orarily ei ,fill In spa -1 ter)
Cemetery. ,. . .T ... ..1r:.:!?.41-....I C 4-2 Date of Burial ' — /0 19.A.i
(If body is to e te ora held,fill in pace later)
The Certifi te eath con :fining the above stated particulars, having been presented to me, after careful exami-
nation, the e appearin1 to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepttd the sam or registration, have recorded it in my Local Record with the above stated Registered
Nnmber, and pn the • . ' thereof I kIEREBY GRANT A PERMIT
th ,,, to hold tempo ' y and.. . . ,i < the body.
(Un a ker ps.person having charge of corpse) (Inter,re ve,or be se dispose of[state how,)
Dated "7 — s1r 19. - (Signed) / .... • *ti���"-
- Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of body to any part of the State (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 SEXTON OR PERSON IN CHARGE OF
I?RFMNISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date o 0 4_./1 wagj r U 19
(Interment or Cress ion)
(N of e , Urrema °rims, etc.)
Section Lot No. Grave No.
(Si d--
(Peraoa is charge)
Address TTT� 5: // .--
���
Person in charge must 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-
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.