LaPointe, Helen NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) 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 and acceptance of a CORRECT AND COMPLETE CERTI-
FICATE OF DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Registered o.
Dist. No.
Tnwk-IT-ilialeaen,5 F4 115 rice 511r„/
-,.-- / County 11/etrceil or City
If city, g" e street address)
Name of deceased AA/ A 2,, ,e),-0 /e. Veteran _c
(If veteran, giv name of War)
ei Sex 4
Single, married,widowed, 'V/
/../ ._ or divorced (write the word) '1 C.414-•C Date,co.f Death , 4. ,.9.70
Age Years Monpis r Days Birthplace C.-Aa 7 4c.e7. ... (NA- far e'
Cause of Death Ly m 4 I y c_ P Sorc. m.7
Certificate was signed by Li ta th t 5';1 Vilma/II M.D.
Address 4 er, ci9,1 51/17,1..5.±....... ....A" file‘4'" 5/f.
Place of Burial (or Removal) v“--et o 'f< (ewe c 45
X
(If body is to be temporarily held fill in,space later) ers-e.t/
. ,,m1 to 4c,7 i(4 5' c er
Cemetery sv Date of Burial 0 i9.2e:
(If body is to be temporarily held, Ail in space later) y
The CERTIFICATE OF DEATH containing the above stded 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 registr ion, have recorded it in my Local Record with the above stated Registered Nu er, and on the basis thereof I HERE-
BY GRA A PERMIT .
to e 5-qt2 74 I) ' ' v knefqi fetv,c,"cri,;(, 4Act e,-- \d4i (4,7 5 7:1-,s,1 ga
(IsIppfe) (AcIpess)
the (4/e,,/,ler' to hold temporarily and ,9• er- the body
(TJMertaker or having charge of corpse)1445,,,, (I re o , or ot .ia ispose of (state how))
Dated 19 (Signed)
minis ra
This Permit is sufficient for the Removal (and Interment or Cremation) a body 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.61.(REV.6/63)(7A2-53)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of `-'e �- was 9/4 19 7
(Interment or Cremation)
t . Ctljaktvt4z� ��
( ame of Cemetery, Crematorium, eq.)
Section / ' 4(4 Lot No.75‘ft 37 Grave No.
(Signed)
(Person in Charge)
Address 35 ��L �L ��- �G° .^v"/ , t3
/RFC/
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.