Primeau, Joseph Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gr This Permit can be signed only by the Local Registrar (Deputy or aubregistrar) 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. Town Registered No._ .._...._......._...
.._..
Village
Dist. No County .. or City
(If city, give street address)
Name of deceased Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex Color • or divorced (write the word) i ' Date of Death 19
Age Years Months Days Birthplace
Cause of Death
Certificate was signed by M.D.
Address .' :c
Place of Burial (or Removal)
(If body is to be temporarily held,fill in space later)
Cemetery Date of Burial frl 19
(If body is to be temporarily held, fill in space later)
Tha 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 Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT �' ( "
to .C:..G.:.l��� r t%' / L.'
(Name) (-Address)
the to hold temporarily and the body.
(Undertaker or person having charge of corpse) (Inter,remove,or otherwise dispose of(state bow])
Dated 19 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the Seats (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 SI X1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
ei4"-- —v---v----ers—g---vsj „.....-
Date oA /..;" _. . -..,. was 41 \ 19 C
(Interment or Cremation)
(N of Cemetery, Crematorium, etc.)
Section Al Lot No. 3 6 Grave No.
(Signed) _ ,a.- .r-1..,.4-' ;,._e •
(Person in/barge) .
r
Address ,.:M�, .• j . ,,, F.
Y
. ;A:"f
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.