LaBrosse, Simon 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 Reed No.
Dist. No.� (G/ County LU `'L--'--7 '•..- or City . r
)if cit , give street address)
Name of deceased --' :�-t " i 2S.-. .-...__ .. Veteran
(If veteran, give name of War)
Single, married, widowed, ,
Sex'2A-e or divorced (write the word)4.X-0 :.-r._. -_- ate of eath ld 19_ 5
Age }''"CU Year,9. Months Days , 4,Bir place,pCause of-Death CJ�- CL� �l
Certificate was signed y.... .. . '2 M.D.
Address c lsy���-__�t-- ...
Place of Burial (or Removal)-..,...4,:-/ ' .L. r--e---
(If body is to be temporar eld, film/sp late %
Cemetery Cam ... 0.4.c..-0 ate of Burial r 3 1%2S_
(If body is to be temporarily held, fill in spae later)
The Certificate of Death con ' ning the above stated particulars, having been prese?-c-a
for e, 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 stated Registered
Number, a on the basis t reof I HER,�BY RANT A PERMIT /�
( e) Address)
the "- v to hold temporarily and the body
(Undert or person avmg charge of core e) _ I ter,remov or otherwise dis ose of [state how])
Dated /- / 19..(PP.. (Signed)
Local Registr
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject 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 "'� was 19 ` N
(Interment or Cremation)
(Na of Cemetery,..Crematorium, etc.)
Section C - Lot No. Grave No. ! —
(Signed) a -„J`' -"---
(Person in Charge)
Address3 tf fE ''
_-%r \\t -r
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.