Tremblay, Ida NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Qom' 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. Registered No. /U
Town, V.
Dist. Na .��: _. County..eJa,&k. .- or City--...
Q /�f' (If city, giv treet address)
Name of deceased �/ .✓. Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex-v' or divorced (write the word)-P_- is z Date of D th ./55 19-.h'
Age.___ _3 Y rs Mo the Days Birthplace s-..a..d.a...--
Cause of-Death. .-!/.. ._.. . ... . .... . �_L4.
Certificate was signed by..,1 , _. ,� M.D,
Address � yCro ...., . . ••-•y-..0 eci_ .._ _... . .... . .,.��
7,
Place of Burial (or Removal)...
(If body is to be a por •ly hel fill 'n space later)
Cemetery• .._.. Date of Burial c-./ 19.1a-
(ir body is to be temporarily 'Id, fill in space later)
The Certificate of Death containing the above stated part' ulars, having been presented to me, after careful exarhi-
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 hove stated Registered
Num ,� o n the b s the of 1- HEREBY GRANT A PERMIT ,�
Cam.. o .... .--• --•-
(H r (Addy
the � (.. . 4 to hold temporarily and - the body
(Undertaker or person having charge of corpse) (Inter,re p•iii or h-f,ise dispose of [state how]
Dated. 2 -1 9 — 194 ' (Signed).!_. ..__ . . ... . .
/ .� ,0 . al Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b.7 to . y part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which cas- 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 of , I was 3 (29� 19_6 r
(Interment or Cremation)
p--, al., ,tenv2,,,,z) 6,,,,,,,,----tt,
(Name of C etery, Crematorium, etc.)
C fill
Section____ 1 12�w T Lot No. / Grave No. J
(Signed) —__ �� • '
(P rson in Charge)
Address ,-J C a-r--674) `-,I-.
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.