Poutre, Paul 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. Pa.
Dist. No.
Town, Villa or City
Name of deceased ' Icr-e....i. • .,cit_{,/ 52--) Veteran
ci , lye...street addre,sitY
Z .) (If veteran, give name of War)
SeX 910c82— Single, married,widowed,
or divorced (write the word) 9.,-)-(11-1A-1)--ei Date each c7204, 19d9C)
Age /7 s 7)ths D s irt lace
Cause of Death
(./
Certificate was signed by 4 M.D.
Address ' Y
Place of Bury; Rem
(If body is to be ayily held fi 1 in space lat6/.
Cemetery A(,42- .....x.g.c.v Date of Burial .2 -.ale 19 d' )
(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 sa i appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same
for re: tration, have recorded it in my LOCE( ecord with the above stated Registered ber, and on t basis thereof I HERE-
BY GA PERMIT
to Nr4. ci,--
' Y
) (A firess)
the to hold temporarily an the body
(Unlertaker or pm-son haying charge of corp.gq) (I remo , or her vi.• dispose of state how))
Dated 407,. --/y 1,0- ...., (Signed) •
Loca egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to a part of the State (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( 18A2-781
ENDORSEMENT OF SEXTON OR PERSON IN
CHARGE OF PREMISES ON WHICH INTERMENTS
OR CREMATIONS ARE MADE
Date of s " 'e, 19 fe)
(Interment or Cremation)
(Name of Cemetery, —_
Section Lot No. a> Grave No.
(Signed) a '�' -����
(Person in Charge)
Address 1 /' j r' ) -
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.