DeLisle, Marie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
re- 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 ERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
r--.) Town,
Re i tered No.
Dist. No. County . '
- e ... ([f city, give street address)
V2
Name of deceased ... Veteran -!----
(If veteran, give name of War)
Single, married, w owed, 1.,...) /r�Sex ���`� or divorced (write the word) '�� Date of D a 19C
Age �Y Nis Moy p.. DaysBirthplCause of7e.A,...
ath ���
Certificate was signed b ..:4 1' - - f i M.D.
A dress �`Q"`Y1 ..�/. ............ ....
Place of B ri 1 ( v ,ace••
(If body is to e m y ' ld, fill in illitir
Cemetery .. ... ... ... Date of Burial �" 1 �
(If body is o e tempos i held, fill in space later
The CERTIFICATE OF DEATH 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, h ve re rded it. in my ocal Record 'th the a ve stated Registered ber .nd ip the i_ thereof_I-kI EBY RANT A
PERMI • it
C —
to e) .., ... d i to ..al ..ar. ._
the to hold temporarily and , • the .r.
(Unde to e�or person having charge of rps ) r, —move, or of �' se •'�.se of (state h ogip �
Dated S............. 19 (Signed)
Local Registrar
This Permit is suffic4ent for the Removal (an Interment or Cremation)of a bo.y 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 (,'" No. 62) is required.
FORM VS. 61. (REV. 6/631 (342-3231
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of Q r17LL was 4ti /3 19k
(Interment or Cremation
1,7L--, , 6.471.1t-_44
(Name of-C .etery, Crematorium,—etc.)
Section . Lot No. Grave No. _ .2
(Signed)
(P rson in Charge)
Address 3s arorj,rX ell 41L a ago N. 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.