Robillard, Francis NEW YORK STATE DEPARTMEN I OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
This Permit can be signed only by the Local Registrar (Deput, 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.
L Town, Village Re istered No la 7
Dist. No: ? (i °./ County v 4�xc: - or City ,.rl� �....J
/ (If city, give street address)
Name of deceased Gr✓ -te � Z Veterans
(If veteran, give name of War)
Single, married, widowed, 1,7
Sex or divorced (write the word)....!'/! Date of De4th..Az----'--4," 19 . ..
Age 4••3 Year Month Days Birthplace -/ (24-e ..
Cause of-Death G _,c . -• -er.c
Certificate was signed by,.... Ti. v.4-<.r M.D.
c-�
Address es ,,...... V
.
Place of Burial (or Removal ..., -a--24/7 .. ...4 ... 7 ./
(If bodyis to b mporaril h 1 in space later)
Y P
Cemetery `aL � mil- - Date of Burial ) // 1917
(If body is to be temporarily held, fill In space later)
The Certificate 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,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numb , and on 7 basis rem HEREBY GRANT A PERMIT
��
to
e) (Address)
the .�,-- to hold tempor ily and the body
(Un aker or person havin charge of copse) (1 ter,remov q rwise disp�pse of [state how])
Dated ~� ���+-rt/ 4....., 19 `7... (Signed).... .. „ U'
ocal R istrar
This Permit is sufficient for the Removal (and Interment or Crema�Ion�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 o ? `'`7 -� rm
( 1 19--tS^-f
Int
Lent r C at onn
i 2714',,z- . -/-7' --,-2,-14— 1
• ,
(Name of Cemetery, Crematorium, etc.)
—5
17
r
Section- r .. Lot No. i Grave No. - --_
^ r
(Signed) - .. Gerson i n Charnel -..,
L '
Address
` �'C
/ (j
Person in charge must return this Permit to the Registr
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)1DAYS 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.