Pepin, Fred NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Q 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 CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Re istered No. 77,
�/ Town, Village �.
./
Dist. No-�2 d County or City
�i If city, give street address)
Name of deceased `1 Veteran
�� (If veteran, give name of War)
Single, married,widowed,Sex ____-- __-- —.— or divorced (write the word) _ �?, ill. t Datef Death - �I v_
Age 1 Years -_ Months Days Birth lace
t '
Cause of Death �� �
Certificate was signed by ,___. __ M.D.
Address Z ,r
, ,
Place of Burial (or Removal)
(If body is to be porarily held, fill in sp ce later)
Cemetery (: i J Date of Burial-__ _ —2 19___7'7
(If body is to b temporarily held, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to , after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for rec' tration, have recorded i 'n my Local Record wit the above stated//Registered Num , and o e basis the �of I HERE-
7/0" ifl ( me) ��}- (Address)
the _. ___ L--'�, to hold temporarily and `�2- the body
(Unlerta or person having charge of corpse) (In� movet�o�r of tse spose of (state how))
Dated 21J._�3 19._._ T? (Signed) 1/���ppp¢¢¢�yyy..�//_f/_�j_, l�l,�
I ocal Registrar
This Per t is sufficient for the Removal (and Interment or Cremation) of a ody to any 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. 6l. (REV. 6/63) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of� 221yrn.e=f-z.)�" was l�r1.- <: 19Y%��
(Interment or ere na •offr
( -ten - ) ;-
(Name of Cemetery, Crematorium, etc.)
/i- - , 6.
Section 1 Lot No. //` Grave No. /
(S
igned)ne e"4-"`
a. ‘7. ,- ,
g )
(Person In Charge)
Address -'� � 4:1—` �'�
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 THE
FIRST OFFENSE. The law will be enforced. Local Regis-
trars are required, under penalty, to report violations thereof.