Lebrun, Omer Form VS No.62. (Rev.)4-11-63-10M (2B3-98)
TRANSIT PERMIT
NEW YORK
STATE DEPARTMENT OF HEALTH
ALBANY
Fir A Transit Permit and Transit Label issued by the Local Registrar of Vital Statistics must
accompany each dead body transported by a common carrier.—Regulation 1, subdivision I.
UNDERTAKER'S CERTI_FICAT
I Hereby Certify that the accompanying dead body of 0 1V\ R. )- E 13 I.t) N
t X„Veteran* who died in the CITY of BUFF.:,.„,,',) ,
el
el (If veteran,give name of War) (City, illage or Town) ' s
Single
d County of E..R..I.•E , State of New York,on.. � IC� 196 C.,Sex. Married
.a 9 Widowed
Divorced
i Age p, years / months � days, Birthplace.. �c� �t' .nrl ccwse of
,wa DeathtA C -1 A4 ' 11--14' -y1''-4-s'4 tfe ?-i ) has been prepared for transportation
.; strictly in accoorrdanc with, eggu�lation 1, subdivision as printed with this blank. Certificate was signed by
a
.0 1•V• rt,r -(--1 ��'� , M.D., Address 666'ELM ST.,BUFFALO, N.Y. 14zus Date of shipment
;: 19 ; Route of shipment ;Point of
sa
shipment ; Point of destination r
yr (Signature of Undertaker) --' «'L'' "' �I .) (..�,A^ev ' :�- i l Reg. No ii6 16
3 Dated '`n ;dam 19 ' c3 f Address i< °, (�,. �.,::.1• - = t..t 4.'-s 1 '1..H_
a^ *Cross out words not applying.
PERMIT OF LOCAL REGISTRAR
DIST. No. Fin 7 Registered No.
Date of issuance.,a' '4' 4t" 11' ''`"C 19 L-s
A satisfactory Certificate of Death for above decedent having been filed and re orded in my office. PERMISSION IS HEREBY
GRANTED FOR THE REMOVAL AND SHI� OF THE BODY
� , (Signature of Loca Registrar) /%4;( Subregistrar
Loca Registrar of the CITY of t BUFFALO , County of E..R..I..I- ,
1. (City,Village or Town)
State of New York.
Only the Local Registrar (Deputy or Subregistrar) may issue a Burial, Removal or Transit Permit
Detach here and give part above to escort or attach to waybill if shipped by express.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF PREMISES ON
WHICH INTERMENTS OR CREMATIONS ARE MADE
Date of l -rr; G S;.-W� was
(Interment or Cremation)
jJftLLi. r. .
p- (Name of Cemetery, Crematorium, c.)
Section fi�' Lot No J k Grave No
•
Signature
(Person i Charge) (Address)
Persons in charge must return this Permit to Registrar of his District within SEVEN (7) DAYS from above date. If no person
is in charge, THE FUNERAL DIRECTOR OR UNDERTAKER 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 Registrar of District 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.