Viele, Leroy Form V&U. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
s: 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 CERTILI.C.pe OF
DEATH, LEGIBLY WRI TT'EN'IN DURABLE BLACK INK. Town ' tered No,-._.
a—
Dist. No.;��5 only... % AtiltOn
or City
(If city,give U
Nam of de seI . Veteran �...
. Single, Larried, widowed, (If veteran, give name of War)
Sex for or divo ed (wnte the word) Date of Death 19
Age D rs ...Months - Birthpl e . . .
Cause of eath� • ,
Certificate was s' ed by �'. ,. .� M. '
Address ...(,2I,..4.n.i. ..IP -
Place of Bu ' or Removal)
(If body is to ..'i; ' orally hFF1dgflll in srspt :
Cemetery.. &..v1!'fc..1.„l.`..A.AA ..• • Date of Burial / ... .....a-.6 19by
(If body is to be temporarily held,fill in space later)
Thq 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 ac ed e same for registration, have recorded it in my Local or with the abo a stated Registered
N •\ , o e eof I HE EBY GRANT A PERMIT .
the. ") ... ill ^(Address)
.to hold tempor. and the dy.
(II a er or person haying cbarg of c pae) (Inter,remove, erwi ■ ose of[state how
Dated .. �� 19g (Signed) ..
Local'R
This Pe t is sufficient for the Re vat (and Interment or Cr mation) of a y to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of 1. ,,*- -_--1 CP 19 l
(Interment or remotion)
^ 7; ( i/7
- ------.77--- - _
://1„.1.2.,- (?,4-4-3-- _
(Name of Cemetery, Crematorium, etc.)
Section 2 7 Lot No. 46`5- Grave No.�-..
Y i
(Signed) .�egi ,.',, ..-.1e!''Te,, (Ye.
(Person in charge) 4. '
v��
Address G /
,/ -
Person ' 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 o:' 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.