Comeau, Laura 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 Registered No.
4
Dist. No. /..L' I County or City
(If city, street address)
1�,
Name of deceased.._, ...C� .. ' .. Veteran ....
/ (lf veteran, give name of War)
Sin�'le,� Tarried widowed, �J'
Sep:.._..... or divorced (write the word) ,. Date of eat 19 6!
Ag ti..Y rs M nths Days Birthplace
Cause of-Death..`,S- p.
�_�. IC
Certificate was si ned .. M.D.
Address )_.•..£.... / It , '
Place of Burial (or Removal)--.,. _J -,ate.... . e--- -' -eAi.
(If body is to bat�atem rari itiel II in space later) fJ''�
Cemetery.._:.1': ,. `.. �� �' /(,� Date of Burial Inn t U 19- ..7
(If body is to he temporarily held, II in space later)
The Certificate of Death containing the above stated par 1 ulars, having been presented to e, after careful exami-
nation,,the same appearing to be COMPLETE, CORRE , 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
Nu r, an on the basis ereof I HEREBY GRANT A PERMIT
j"�'— f�rf.?-� /�' 6 �`!r'�l-�? ' C�/t(,y-'—�.. Cyr...'`. .
me .r --- (Address)
the._. . 2t % ' )�--! 2c : -to hold temporarily and. / the body,
Undertaker or person having charge of pse) (Inter,re ove, or oth ise ispos f [ ate h w])
Dated . 1 19...1<?.,� (Signed)� - 'Y
ocal Regis(ar
This Permit 1 sufficient for the Removal (and Interment or Cremation) of a body to any part of the State ( ject 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 OR
CREMATIONS ARE MADE
Date of_ _was —19_
(interment or Cremation)
(Name of emetery,Crematurium, etc.)
Section_ c Lot No. 75)rGrave No.______
•
(Signed) __.
(Pers n in Charge)
Address ''e ;
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.