Germain, Lewis Form vS.!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Or This Permit can be signed only by the Local Registrar (Deputy or subregiatrar) of the Primary Registration District (Town,
Village, or City) in which the des occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIF A OF
DEATH, LEGIBLY WRITTEN IN RABLE BLACK INK. Town Registered No._._.. —
Village
Dist. No���''� Couaty.. .4,,, or Citylty 7246)"1-e.a,-14-1'
i (Ii city, give street address)
Name of deceased ` Veteran
Single, married, widowed, ((f v era give name of w")
Sex. ./ /' Color.. or divorced (write the word)...].(4/ ' t. Date of eath....Q -;.• d.... 19. .r.
Age .6 Years onths Da . Birthplace ) ,{,c�.... . . +� Ci
Cause of Death (T..; ., 49 ,1
Certificate was signed by 411.p. ..m,.,.vc, I..... ' .. . . , c 9. , . < ��yy� � a+ rM.D.
Address Ali 1 a ,...,... C!(,�,,. .27
Place of Burial (or R- oval) " Ir-C:t:r,-.� v
(If body is to be temp era+ held,AN in j.ace la r /
Cemetery ��... . i .. &.< .. Date of Burial 9 / 19.6.i
(If body is to be tempora-ly held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded in my Local R o • with the . . .ye tated Registered
N , the basis f I HER GRAN , i PERMIT C—N
iif
the a�G)lr.r�,... .. to hold temporarily and �) the body.
nder r or perso a charge pee) (In , r:. .r:1 of how])
Dat 12..19. (Sign�* ,�.00" '/, � ... ► t
This Permit is s fficient for the R moval (and Interment or Cremation) of a body to any part of the State ( jest local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is requ'
EVDORSEMIT OF SI X`IUN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of N2=1-1-z/was � C" 19 C.7
(Interment
t •
(Name of Cemetery,
Section Lot No.H44
Gr
(Signed) '(-, -�
(Person In chargee))
Address Y /4c
--are„e4-Th
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
fray' above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, 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 re-
quired, under penalty, to report violations thereof.