LeMay, Robert NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
per' 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.
Town, Village �Q� I �" �oRegistered No.s5 7
Dist. No. -- County 4i.c 244: / or City r/y" �u•�- 1 , •
(If city, give stree't'addresw
Name of deceased lr;_,�r.f [/. .it 77 Veteran �UI4 -
0' Single, married, widowed, •
(If veteran, give name of War)
Sex or divorced (write the word) f Date of D th-- ,��,,,r, ZS 196-5
Age 4/.3 Years. Months Days Birthplace.. ��f ,t�
y �'
Cause of-Death r/
Certificate was signed by er- r • M.D.
Address----- ..`f..- .� 17, f
Place of Burial or Removal) OLa�`xJ4246c,if(If body is to be to arily ,1d, i space later)
jCemetery__ - L Date of Burial. Zleee e2e- 19 .S._
(If body is to he temporarily heI , fill In space later)
The 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 ecord with the above stated Registered
Num a., nd on the b sis thereof I }IEREBY GRANT A PERMIT ���v
to ? l 7G r� l . 24-,e 4.-
Name) ress)
the t„ to hold temporarily and the body
(Undertaker or person having charge of corpse) (Ipter,r move,or otherwie d pose of [state h
Dated...22_--,y.? 19.4t (Signed) �.. , e�.-i .
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (s ject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No, 62) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
. h�
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ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of was _19 ,
(Interment or Cremation)
(Name of Ce ery, Crematorium, etc.)
Section P• Lot No. /�` Grave No.—l___
(Signed) __— 4-02t-
(P son in Charge)
Address
G.� ��Q.BI.A
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.