LaPier, Victor NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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-
TIFICAT OF DEATH, LEGI LY WRITTEN IN DURABLE BLACK INK.?_._.. ._ eglstered No
Town, Vi11ag�
Dist. Na. County.. ... l/l� or City ---
N (If city, give street ad�r ss)
Name of deceased �..,! - �� ?�...ri,,r. Veteran
1
. If veteran, give name of War)
Single, married, widowed,
Sex <.. or divorced (write the word).. . ...Date o& eath.. .--" 19..-
\trths Da - Birthplace r "Age... : .. ,..,.. rs.. Y
Cause of-Death. . ' .
y.. E .•I ! `Nf r ate:
Certificate was sI b .. ... � t•• •• � � '• ••' •"'••"
Address _ �/ I�
Place of Bu .1 ornova "\ ```�"�'
(If body is to b-�m :rar ,fi311 s ee later) ,c a.7 I t� /
(If body is . .e to porarily held, -.- ,,:'� 4,,. •• ,• �' ..Date of Burial... ft 1�
Cemetery.
fill in ace later)
The Certi Cate of Death containing 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,
cepted the e or regist tion, have recorded it in my L Re rd with thl • •e stated )Reg tered
Nu `and on the b s thereof I ER Y GRANT A PETPL5 IP .
( �to ame) (Address)
the 1...1........... .. to hold temporaril i thody
(Undertaker or person having charge of c ps (Inter,remove, wis(. - a of [state how])
Dated / ,..- 19 (Signed) . . " "
'� �. Local 'Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b to any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case Transit Permit (VS No, 82) 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__�
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section____ 1 E Lot No. t% Grave No._____
(Signed) _____
(Person in 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.