LaDue, Averile Form VS.Si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gr 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 CERTIEICE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.. Town egistered No— -,"
r..... Vitiate-, cm
Dist. NoCC57County.L2advAP---,- or City
[If r,ty, give str address)
me of deceased JAN 4,i 1...-g C i.. L-. \ t/N 14 aft) E Veteran e44'....01-1.)
, -)
.(... . f...ColoL
Age.... .,-.. .. ..,.....Y ars..
N
,4_,L.sorincte,ormceadrried, widowed,
(write the word)
.., onths . ... .Da ( eteran. give name of War)
,...----
_. 11—,:___,4' ate of Death w. 19. .,--
Birthplace
, N
Cause of Death
Certificate was signed . -,N-0
‘`erN't:'' M.D.
AddressZ2—....- • i•or.,•-v.-....,":_art ' ,........, E-0-Q-0.--
Place of 13 •arIttor Removal)
(If body Is to be te erariy heildlfill irispace te --7r—
Cemetery zr A-Ae-"L L, ./.44:2-A.,.., r"e"-----c.-9-- Date of Burial.. (--- ? ---Kr-3 19
(If body is to be temporarily held, Ell in space later)
Tho Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearin to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the a or registration, have recorded it in my Local Record with the abov stated Registered
Num, -...,. and on tt ' eto,_of I HEREBY GRANT A PErkIIT
to 3 c
the to,. to hold ternporaril and the body.
(Ur:taker or person having char of corpse) (Inter,removi,&othrrise dlsnose of [state h )
Dated --) --p.,(2... 19 4-. (Signed).
‘4.neal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a bbdy to any pest 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date ''�z-�� _ was ,f. ti 7 19
(Interment or
(Name of Cemetery, Crematorium, etc.) J
Section Lot No.9(o\-J Grave No. /
(Signed) /caC2 �.(-6;
(person in charge)
Address OfF‘76/7/2..2-7,--
7) '7Person in charge must return this the Registrar of his District within SE
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.