Duross, Frances NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fAr 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
Town, Village �,.`—
Registered No. �1�
Dist. No. .. C- \ County LYCAXi\.✓1N, or City 1 W1C + 2
c.
give city, give street address)
V ame of deceased c..L\Cs 4 `�:`c , Veteran ..:3c'
(If veteran, give name of War)
Single, married, widowed,
;ex or divorced (write the word) },•,\.imac Date of DeatJain-
age Vo") Years Months Days Birthplace t , 4.-r-
2-ause of Death ...( .N5 S'A5 L " 1.i
certificate was signed by C. a'(\ -s3.-` ,,,I,,N\ M.D.
Address ., i �4,.N
'lace of Burial (or Removal) + '.;•_, �.Ag':,l
If body is t)e to po aril- held, tar i space later)
-emetery� .. .. �i."k 'i ._ Date of Burial V... \ 19 7 ..
If body is to he temporari y he d, fill in space later)
'he CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
ame appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra•
ion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
'ERMIT (--
(Name) (Address)
he �pQ��� to hold temporarily and Cti3!f .., the body
(Undetta er or person aving charge o corpse) (Inter, remove, or otherwise dispose of (state how))
►ated .N...:b.k 19 i
(Signed) /\- ' �,� ;
' cal Registrar
This•Permit is sufficient for the Removal (and Interment or Cremation)of a body to any part of the State (subject to local cemetery or
ther regulations) unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
`ORM�IRE�V. 6/63) (3A2-323)
ENDORSEMENT OF SEXTON ON YLKJoIN in t,nnrc\Jc.
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
I
Date of - r�(�"11',tt.� was / 4-1 19
(Interment or Cremation) a
/ �/' I
l c_ V� 'L47--s\
(Name of Cemetery, Crematetium, etc.)
/
Section
dd.4U / 'Lot NO. .3/�r' Grave No.
40l ?
4"./. a 4.--(--r---7-t.----/
(.....
(Signed)
(Person in Charge)
Address
# / /� /c '
/G
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 UNDER-
TAKER 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 UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.