Lemery, Helene NEW YORK STATE DEPARTMEIT OF HEALTH
OFFICIAL BURIAL (OR REMCVAL) PERMIT
' 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 ant acceptance of a CORRECT AND COMPLETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered No. ---1.` ,-
Dist. No7�7 Co ty Town, Vilage
� or City
Name of deceased e-
If City, give street address)
7Veteran
(If veteran,give name of War)
// Single, married,widowed, p ,
Se ---- 'h1.-GexQ - or divorced (write the word) .- �..-- Date of eath 1/ / 19..-
Age 6_'" Years - Months ays Birt place
Cause of Death --'�-- ,--C.�� -Li) -_ __ ,, ,-_,_
Certificate was signed by _-_-Oa,-;L W M.D.
Address ..,9_ ___ _Place of Burial (or Removal) - .- - . - - -.. .CL,-./--�.y./-; )
(If body is to be orarjlys 1%1., Ile in spa e later) o
•
'Cemetery C� i --� /c - Date of Burial (AL 19 7?
(If body is to be t mporarily /ld, fill in space later)
The CERTIFICATE OF i ATH containing the above stated particulars,aving been presented to me, after careful examination,
the same appearing to be COMPLETE, CORRECT, AND SATISFACTOX AS REQUIRED BY LAW, I have accepted the same
for registration, have recorded it in my Local Record with the above stall Regist ed��r, and the basis the eo /ERE-
BY GIFT PERMIT • (7j C '
( ame . (Address)
the to hold temporarily id �' �'� t. the body
(Unlertaker or rson a ng charge of corpse),, (Inter, re , or o erwise ispos of (state how
Dated 3 19-- ' • (Signed) -. ))
.. t This Permit is sufficient for the Removal (and Interment or Crenion) of a to any part of a State (subject to local
cemetery or other regulations), unless removal is by common carrier, Which case a Transit Permit (VS No. 62) is required.
FORM VS.61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of
was 19 'f'
, ,
(Interment or Cremation)
(Name of Cemetery, Crematorium,:"rte.)
Section L Lot No. 2-1 Grave No.
(Signed) - ..
(Per n in Charge)
Address G
Person in charge must return this Permit to the ye-4,`-
ot ms D: _• . .,.:,,..r -. —ow au ve date.
If no person is in charge, the FUNERAL DIRECTOR or
UNDERTAKER MUST SIGN ABOVE STATEMEN
write across the face of the Permit the words "No perso
charge," and FILE PERMIT WITHIN THREE (3) DA
with the Registrar of District in which cemetery is locat
SEXTONS, FUNERAL DIRECTORS and UND
TAKERS violating the law relative to the return of perm(ts,''
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.