Breault, Stephanie NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ILA 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.
Registers No. r�3•
/� /' Town, Villageill_
Dist. No. __5 0/ County `--'��<fin/ . __- or City, If city, give street address)
Name of deceased -�'_� . . - -- . - . - -Q� -/ - Veteran
(If veteran,give name of War)
Single, married,widowed,
Sex __‘":1-4 or divorced (write the word) Date of Deathe7 1917
Age Ye nths Da rthplace
�Cause of Death ')I - • F. SJ Qtivz.g ,
Certificate was signed by M.D.
Address f/'!4A4 Ci4. . .. �� & '
- ?"1-A)
Place Burial o Removal _ _ � i
(If body is to be to �ra�`rily�head f'1 in spdce later) _ �' I
'Cemetery J..1 ____G-_A IA! Date of Burial /7 19___ _a
(If body is to be t mporarily 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 registration, have recorded it in my Local Record wit s the above stated Registe ed Number, and o the basis thereof I HERE-
BY1 GRA A MIT ‘ 7t4/G J J 7 - 26,
(' XL
(N me) (Add ess)
the . to hold temporarily and4 the body
(Unlertaker or‘per on having charge of corpse) (Inter, remove, or otherwise dispose of (state how))
Dated 19-- (Signed)
! /r c 1 egi- ra
This Permit is sufficient for the Removal (and Interment or Cremation) of a b s 4 .- o. jest to local
cemetery or other regulations),unless removal is by common carrier, in which case a T,: • Permi (VS . 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 ,�
(Interment or Crema 'on)
(Name of Cemetery, 7`re tom' eEe
Sectio Lod Grave No. '29'
(Signed)
n
Address
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 4
I
SEXTONS, FUNERAL DIRECTORS and UNDER-
TAKERS violating the law relative to the return of perm'
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.