LaPoint, Clarence I LWY WKR 3IAIC NC1'AKIMCPII VF I'1CALIPI
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Er 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 COMPUTE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. , C.(
Registered No.
7 Town, Village %�, -
Dist. No. County t t- `/( --�- -City T >C c k \—_f,, �-�= ;/ ,
L. ,- If city, give street addre
Name of deceased =_-�! _A.,i ->k -/ �--E:...sj I. -__-;= c,y,_'r` Veteran '
(If veteran,give name of War)
i—i ` " Single,married,widowed,
Sex � c-1 ' or divorced (write the word)'-2 r x Date f Death /C,/ % l 19.
• ,
Age ..4 Yeas the /' Days Birthplace ;
Cause of Death ;;�_-c'ti (-( :s...� _._,u.-4- `` .� -S= (
Certificate was signed by .._ ,-4<4_4. ,.. , .,- .c. M.D.
Address _.5 9 _:,-� t A $L,X — /L y
Place of Burial (or Removal) __ .v.,.�---n.. • G-:_ / LJ(If body is to be porarily held,fill in spice later) 4
'Cemete ;.'c_- L /"-- ,-,,--.;�_
ry T y' L_wt..i:_�v Date of Burial 4' 19
(If body is to be temporarily 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 re istration, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HERE-
BY ( RANT A 'ERMIT ,
j
S
t0 ., LL 1.if'I, �-n '- L-�---i"k--a ---c'1 a` ( G. ii ) /1 / �� „ S_ �. ,
Name) / (Address)
the '( - ,_: -_iz :_i to hold temporarily and :' --,« '�- the body
(Unlertak or person having charge of corpse) (Inter, rem or otherwise dispose of (state how))
Dated f;_.<` I 19--- 1.(-- (Signed) �j j
caYlie�istrs�f�a ,
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to ny part 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) (4A2-179)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of LG�li/was (�/1971
(Interment o
g'6'..).(--€' V.- -1-e)-
(Name of Cemetery, Ccpsxs `-*`^^3 ate.)
Section
QNo. �J/ 'Grave No. l
(Signed) . '
(Person in Charge)
Address /e0e<5j jeCq,,e,e_.' / 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
UNDERTAKER 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 UNDER-
TAKERS violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOL-
LARS NOR MORE THAN FIFTY DOLLARS FOR TIDE,
FIRST OFFENSE. The law will be enforced. Local Regis
trars are required, under penalty, to report violations thereof.