Barrett, Lorraine NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
itgr 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. Ai
R�stered No.
y G!22��1 Town, Village �R �� .
Dist. No. S�41 Cunt City
If city, give street address)
Name of deceased___.. __ _. / ,�� Li� Veteran
(If veteran, give name of War)
Single, married,widowed, �
Se .. __ _ or divorced (write the word) • Date Death c3/ A.3 19._227 '
Age S_, Yea o}tbs Day Birthpla
Cause of Death , t teL.Q__ '
Certificate was signed by ./...;_ _._ _ �_. M.D.
Address -65 ,
Place of Burial ,(or Removal) r__
(If body is to be to p rarily ql it in pace later) , .
)
Cemetery �_ Date of Burial__.3A 19 a,
(If body is to b temporarily held ill in space later)
The CERTIFICATE OF DEA H 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 'stration, have record d it in y Local Record w' the above stated Registered Numberand o the basis thereo I HERE-
BY NT A PERMIT--
to - ��' ( 3//I tcl
( ame) (Address)
the to hold temporarily and ,.._ i the body
(tinier kerpe son having charge of corpse) (Inter, - •ove, o otherw dispose of (state how))
Dated /fG 19.',7i' (Signed) / .
This Permit is sufficient for the Removal (and Interment or Cremation) of Cy to any part 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) (6A2-130)
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of f" - was � - ' 19 '27
(Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section 4 Lot No. K z Grave No.
(Signed)
(Person in Charge)
Address '�� �_ 7 7
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 locate&
SEXTONS, FUNERAL DIRECTORS and UNDE ?
TAKERS violating the law relative to the return of perm
are liable to a penalty of NOT LESS THAN FIVE DOL4
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.