LaPoint, Delia NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
nr 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. /7
�.� / r' TOW if, Village.— Re istered o.�J
Dist. NoS.l..6 t./ County.-!mil a-I .,.,..... ...or City .._ �.., .�"
4 (If city, give street address)
Name of ased 4,.. :;25 Veteran
(If veteran, give name of War)
Single, married, widowed, /t
Sex... a or divorced (write the wordy' 7 -e Date of D h-. 2/ 19 ?
Age ,���!' Year Month. Days Birthplace. .. .�: %:: �-.. ....`..._ 7
Cause of-Death. -� •
Certificate was signed by. ... .C.Zr.., !. ..-' , M.D.
Address ....,..e. ,,f -
Place of Burial (or Removal),l _sr.,. ..
(If body is to be tenAgarily he , 1 - spat later)
Cemetery -- 2 ate of Burial.. ..s~„re` ,/ 1g444.lS
(If body is to be temporarily e d, 6 space Inter)
The Certificate of Death ontaining 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 s ed R istered
Numb�and-on the ViS reof IallERyBY GRANT A PERMIT �//? - 16
the (Addy
- to hold temporarily and the body
it7-.,d...4.4.aker or pepson ha ingarge of corpse) t r,remove, or otbar dispose of [s e owl)
Dated -r 19. 0 (Signed)
Local Reg strar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Sta ubject 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)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS qR
CREMATIONS ARE MADE
Date of /a7/ / 6 was Cf. 19
(Interment on
awe
(Name of Cemetery,.Crematorium, etc.)
H
Section .L -• /'1 Lot No. /(D Grave No. --
(Signed) _ Lir
(Person n 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 (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.