Lariviere, Edward NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fgr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. t2 [f"s�f
.-� r '} Town,i .11egc Q Regis d No. [ J /
Dist. No. o ty LA...) os-.Cits}-
(If city, give stre ddress)
Name of decease ) . "t- .i.—,,-.2^-e Veteran
(If veteran, give name of War)
Single, married, widowed, pp //'' Ct+
Sex or divorced (write the word) ate of Death ..:. .6 " l..... 194..
Age . .... ears ... . onths +.... ..*.`...Days ce ,.
Cause of eah .. . .:1:-.. . .. .. .... .... L ....
Certificate was signed b .. `_': ..... . ( .D.
Address ....t....�1 .... ... .. ,,,.. .. ..
Place of Bu '_l (or : - •:1
(If body is to .: _m . - w e ., fill in ace lat
Cemetery .f -Wi� / Date of Burial 6 ._ /2.... 14,
(If body is t. -mporarrl ilkd, fill in space ater
The CERTIFICATE OF DE H containing the above stated particulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, ha recorded it in my al Record wit he above stated Registered Number d the ba \s there. REBY GRA
PER �/
to ; / ��
te) .. �a ss)
the \..1 .......... to hold temporarily an .... ... body
(Un e a er or petso having charge !ogle) r, remove, or wis ose of (state h )
Dated I — 19��...( (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation)of a body to any rt 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 OR
CREMATIONS ARE MADE
Date of �i waE J 2j 19 (0 9
(Interment of non)
24,
(Name of Cemeter , Grettia . .)
Section ' Lot No. Grave No.
(Signed)
Person in Charge)
Address t3 3-ro-a'r , 46iivoa'catii y.
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 District 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.