Terreault, Lucile NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
QW' 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.
Town, V' e
Dist. No. 60 unty (4...i0,//1.. or City - 14' ------
3li
If city, giv t t a��
Name of de as �iC�: � ------ �- --� -- Veteran
of veteran, give name of War)
Single, married,widowed, A.Sex _ /--. or divorced (write the word) - /i Date of Death A. 19.....
Age ___ C� Ye _ Months Da s Birthplace
Cause of Death r
Certificate was signed by _-._t�- __ • M.D.
Address di.
Place of Buri 1 (or Re 1) -
(If body is to be e porarily h f' in a later) // n
Cemetery_ Date of Burial 1l "'L. . 19.-,/-_�
(If body ' o be t porarily eld, fil in space later)
The CERTIFICATE OF DEATH containing the above stated particulars• having been presented to me, after careful examination,
the sam::ppearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for regi- .ation, have recorded it in my Local cord with the above stated Registered Number, and on the basis thereof I HERE-
BY GR i ERMIT
to ___ d ��
( me) d•re.s) J
the to hold temporarily and �,a the body
(Unlertaker or person laving charge of cor a nter, remo or , Z. lse of (state how))
Dated fl 1 (Signed) i 9
Local t�/trar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any rt of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit ••rmit (VS No. 62) is required.
FORM VS. 61. (REV. 6/63) 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of Interment was Nov• c' 19 79
(Interment or Cremation)
St. Aiphonsus Cemetery
(Name of Cemetery, Crematorium, etc.)
Section r- " 1'. Lot No. Grave No.
(Signed)
( erson in Charge)
Address _ . , ;' ,' `t ',.
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.