Henrie, Leland 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.
Town, Village
Registered No.�5-6
Dist. No. Eon County --,---, or City c vl.._ 9--e--e--R
(If city, give street address)
Name of deceased c�s ---e- Veteran A' J.L.
(If veteran, give name of War)
Single, married, widowed,
Sex 22 or divorced (write the word).. ,1.4?r^=s 1 Date Qf D th /,2. -.2 19
Cr-
Age 2° Years Months �..r._-.Days n Birthplace. s.�.7.--. ..... .
Cause of Death �gqe��%uZ -L�� V•a .C.�(�f e—Lee?:lr
Certificate was signed by \D.- M.D.
Address 4?cecv Place of Burial (or Re,moval) t.... n,�'., .... :
(If body is to be temporarily field, fill - pace later) /
Cemetery It - J Date of Burial /-2 -r 19.6.
(If body is to be temporarily held, fill in pace later)
The Certificate of Death co taining 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 re istration, have recorded it in my Local Recor f ith the above stated Registered
Numb and on the basis there •I HE EBY GRAN A PERMIT
(N e) (Address
to hold temporarily and the body
th(Un ertaker or person having charge of corpse) (Inte ove, or oerwi6e pose of [star/fw])
Dated .7, -3 19 �i.3`- (Signed) fX YY -�.
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the Sta • (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
4Date of '`�'"A"' was i Z e 19 )
(Interment or Cremation)
(Name of Cemetery,Cr atorium, etc.)
Section v�� Lot No. I Grave No. _
(Signed) __.—___
( rson in Charge)
Address ,_, --ta.t.:-I;ZgZe .
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. 1