Lewis, Bert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ieF' 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.
/f Town, Village
egistered No. 5.,;
Dist. No:--5.,CS.7..-- County.. C -P or City (If city, gives et -t
address)
Vame of deceased Je. �. C. c ,' freer Veteran
• (If veteran, give name of War)
Single, married, widowed, ,
/
Sex_._... .C.,'" �. or divorced (write the word)._..�G '. Date of Death...,!/�� 19.1,�.!1
Age_,,, rs. Months Days Birthplace..".,
Cause of-Death ( `�'L- _ - L-a=•z. C. :? 44:1.a
-A.
Certificate was si y..I 1 .t._� I
i M.D.
Address ; :`s. �,., .,.c,L.
Place of Bur (or Removal)4.-_,• <C.e,.__f.:?L :CI.,..__:s_c,_, -a ..4?.,:i..�S
(If body is to t porarily held, fill in sac ate,') - .__/
Cemetery_ .t._1.=�,6.=._ ...-.L.-.--... --t,-.4.4 4 4- e- , Date of Burial C 7- 19L..
(if body is to be temporarily held, fill In space later)
The Certificate of Death containing the above st ted 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 or registration, have recorded it in my Local Record with the above stated Registered
Nu , and n theys> ereof I HEREBY GRANT/ A PERMIT y�j f
to ��t,fl k `„._ :d��..,.„.l!r .f zi."t.' ..lice-. .' .a.. >%1 ii- bt,
(Ar
the { to hold temporarilyand ;.t = the ody
( rta a or pejson having charge of copse) ,/ (Inter,rem6ve) lithe is spore of [state how])
C y�r (Signed) j/' --4_-e G�jc%: _c e-?—;4_..z.�� --4 Dated...... .... � ht 19.4 �� ,.---
i, a Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b o a,y part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which cas a Tra sit Permit (VS No, 82) 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
��
Datej� � ( wa17 l9
T
(Interment or re tion)
7/7:y.'-.7 :- . —
(Name of Cemetery, Crematorium, etc.)
Section . t No. Grave No.�14
(Signed) _7 _ x
(Person in Charge)
Address, j E l.- t,-4n....-Ta
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 (3) 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.