Viger, Ernest NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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 CER-
TIFICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
I J Town, Village ti3ter
ed No Dist. Nod.�r. _.. County..L / - of Cityi6 �� '
(If City, give street address) ,,����1
Name of deceased..d..----ri.—{,-./.1
Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex_.. or divorced (write the word) Date of th — — 19 C`f
Age 3Xsars..._. onths ...... ays/ ' . Birthplac .._ •
Cause of`Death. L .. _:ram...
Certificate was si ned by... . . .. .. • �.. .. M.D.
Address . .4 .., .- -- - 71 .
Place of Burial (or Removal) ., e4- /�ctiit
(If body is to y�t porarily hel., fi 1 in space late
Cemetery.a.;,..c..,c,.t.x�-L,l. i .L¢' [1....-ykt474, Date of Buri • / /-- 19/t
(if body is to be temporarily held, fill in space later) '
The Certificate of Death containing the above sta d 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 ecord w'th the hove stated Registered
Num er nd on the b t�f of I,f EBY GRANT A PERMIT .17.21a14
(Address /
the - .. to hold temporarilyand - - .—' the o y
dertake or perso having charge of co se j (Inter,remove, or er e of [state how])
Dated • /4 19L't (Signed) Z) . -.-_ .-,--l� .
a gistrar
This ermit is sufficient for the Removal (and Interment or Cremation) of ody ny part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a ransit Permit (VS No, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date o22 was - 17 / 7 19 � 5
(Interment or Cremation
(Name of Cemetery, Crematorium, et .)
G - ` ' "0
Sectiog 4'A[ . Lot No./V C Grave No.L3ceezd
(Signed)
(Person in Charge)
Address
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and FILE
PERMIT WITHIN THREE (9) DAYS with the Registrar of Dis-
trict 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 required, under penalty,
to report violations thereof: