Lamoree, Herman NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
I 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 No. �J
/ ) Town, Village
Dist. No. -_L5 6 0/ Cou ty `� City
If city, ive street address)
Name of deceased (�h I 7 -e 4. •Veteran CO •
(If veteran,give name of War)
Single, married,widowed, ��� J fY
Sex or divorced (write the word) __ /Date of each _.___ OA 3 19
Age �7• Years Months Day , Birthplace s
Cause of Death ......&
Certificate was signed by = /�jf�f% __. M.D.
Address _-- ---
Place of Burial r Removal) �.�
(If body is to be t m rarily held, I in sp pe later) //
Cemetery ..A-�Q __,L 24s,1__ Date of Burial ..C17 19.___7i
(If body is to be emporarily 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 with th above stated Registers Number, a . on the asis thereof HEE-
BY G ANT A MIT Are-A-A-4,i_ �' ‘ . i //to >�
(N e) (Address)
the to hold temporarily and -_ the body
(Unlertaker or pers n hay' g charge of corpse) ` r, re1Se, the vise dispose of (state how))
Dated 70_. 19 �0 (Signed)
I Registrar^� .
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to ny part of t e Stat (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
,--`,/-�,i- lam`-T-1 « ,
Date of - ' was 19_.4
�� (Interment or (3re�aatiaa.1---
lam-/--f�_.f 7.,E��t4.-6
(Name of Cemetery, Crem
te
Section Lot No. Grave No.
.. I L'2 �'-� j7C�i—l�
(Signed(
(Person in Charge)
Address � 17 /:/ ^`
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.