Charlebois, Florence 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.
S�. ?County
� Town, Village
Re •stered No.
Dist. Na S '�Y"`'1-".., or City
(If city, give stree ddre-
Name of deceased A7ri...Q Ehe C1. e 1-h\421-F Bo L,S Veteran '
(If veteran, give name of War)
Single, married, widowed, //
SexNc..--- or divorced (write the word) ' ..Date of Death.... . . ''-' 19h.C
Age rs__._. onths Days B. hplace
Cause of-De th_._. ... • ,
Certificate was si ne_d by... _,.. - _._. .. M.D.
Address-. . -- :: .. ,......,.... „,t
Place of Bur. (or R-1 o a ,.1._... . A r/'
(If body is to be aril�•,0 1T, )ice ter)
Cemetery Date of Burial 19(.t�
(if body is to . e porarily held, fi I space later)
The Certificate of Death c. taining the above stated particulars, having been presen 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 Loc Recor with above stated Re istered
Nun• per, andlo : - bls th.2,0;kof ERE Y G T A PER
the.... ( ress)
-�.- • � :�.= - to hold tempora ' and �^'�.. .-_ e body
( de ker or person having charge of co e) (Inter,remoy�,�w�ot wis dispose of [state how )
Dated .. 19..6,C (Signed) ' . . 1/..-i`� ---
l Local Registrar
:
This Per it is sufficient for the Removal (and Interment or Cremation) of .ody to any part of the State (subject t(o 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 dl(.-�V -k was a? 9 19 S'
(Interment or Cre tion)
(Na of Cemetery, Crematorium;.etc.)
Section 6 Lot No. 7 Grave No.
(Signed)
erson in Char
Address 4f�2.C.(�
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.