Lesperence, Robert 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 No.
Town, Village (I /' /V
Dist. No. /6)/ County or City
/ If city g've street address)
Name of deceased V � -,� , Veteran
i (If veteran, give name of War)
Single, married,widowed, ��
Sex �1 a�� or divorced (write the word) 1 Date of Death :.1,, : 19..-.-
Age c-7 Ye rs Months Days Birthplace "( y
Cause of Death -L-
��
Certificate was signed by —37--e-e'e M.D.
Address '�
Place of Burial (or Removal '-4 .
(If body is to powily hell,jilt in space lat )
'Cemetery___. (O .may✓ Date of Burial ifi1--ea�.r.j.y__ 19 7-
(If body is to be temporarily 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 the above stated Registered Number, and on the basis thereof I HERE-
BY A PERMIT C— • J I 'Cl -e'
(Name) .1 ''�� "— 62 Jress)
the1Z9 ��-2_ to hold temporarily and the body
(U ertaker or erso having charge of corpse ( re , or othe 'se (st e h ))
Dated �—'t 7 19_-77 (Signed) R...--
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject t 1 al
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
laiy�Girt1-k_j-' � ..
Date of was `�. ! 19 7'/
l (Interment or Cremation)
(Name of Cemetery, Crematorium, etc.)
Section '` - Lot No. Grave No.
fi')—L
(Signed) �c. /,
(Person in Charge)
Address
re2(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 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.
f,ESI'EINCE Robert V.• Lot No. 11 2
Address Section No.
Harri Aen OvP 61 PnS Palls, NT_Y_
Owner Mrs. Joan Lesperence Plot Oneida
Date 3/3.9/79
65 Superficial ft. @ $250.00
Location Bounded on the North by Arnold, East by Path, South by Vacant, West by Vacant
Corner Posts
Remarks
Deed No. (and changes) 15214
Payment Record Paid in full 3/19/79
Form No. 01
Record of Interments
-'T o+3
1 �,:nn/ h. ) 3- a 15
2 Robert V. Lesperence (3/19/79) 1 ,1> 3. kt..! /19
3 I 7
4 18
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LrSPFRWNCL, Robert V.
Age: 51 ( --
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Cause: Myocardial Infarction ,,,
Lot Owner: Joan Lesperence Lot # 12, Oneida Plot
Grave # 2
Case: Cohcrete
Died: 3/16/79
Interred 3/19/79
Undertaker: Regen Rr Denny