Giroux, John 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 224'ttA-i ..y.egmt red No
Qa...-e-E4 ri/ T Dist. No.--7.:.4.(•:)..1... County ttelare or City
Name of deceased 172:4-0-14A-4-4 A-1-";&-c-1-74-
Ctdtke (If city, give street addreiro
Veteran
(If veteran, give name of War)
Sex 411-fili4 Single, married, widowed,
or divorced (write the word). .1.:VAIte-q.. Date of:Lim...41...-4.--vutcei
.r 47 7
Age Y
is ,7 AkA -Liars., Birthplace ,
Cause of-Death
Certificate was signed by it) M.D.
Address
Place of Burial (or Removal). 7;4' 4
(If body is to b,eAoy lyorari 1 spec later)
Cemetery. Date of Burial
(If body is to be temporarily held, fill In space later)
The Certifilate of Death containing the above stated particulars, having been presented to me, a ter careful exami-
nation,.the same appearing to be COMPLETE, CORRECT, AND SAISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the bo e stated Registered
Numb d on the bus' thereoLI REBY GRANT A PERMIT
4 y
to
I
( e) (Address)
the to hold tempora • and the body
nderta r or person having charge of corpse) (Inter,re ve, or,sopwisetre of [state how])
Dated LI 19.4,7 (Signed).
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body 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, 82) is required.
Form VS. 61. (Rev, 6/63) (3A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS CAR
CREMATIONS ARE MADE
Date of4„ _____was 19
(Interment or Cremation)
(Name of C net ,Crematorium, etc.)
Section__.._. 73. Lot No./7 Grave No.
(Signed) •...f.t-,Q
( rson in Charge)
Address e�+C„�� 2 -
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 Iocated.
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.