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Boulet, Baby boy Poem V$61. 6-8-34.50,000 (17.7901) NEW YORIK- STATE DEPARTMENT OF HEALTH OFFICIAL: BURIAL (OR _REMOVAL) PEIthirf_ This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Registration District (Town, Village„ or City) in which die death occurred after the FILING f a COR AND C AIPLBTB CERTIFICATE OF DEATH,LEGIBLY WRITTEN IN DURABLE BLACK INK o. Q1 R tstered N&..., 37. Warren• Town `County 8T Village_ . G1 I.S .rail. .. ..... .............................. .... » » or Ity (If city,give street address) Nameof deceased.._.. _� ...»».. ».. ._.._ •.».•....».... •...... _ :__ -.. . Ingle,mar d widowed ''= --Color _ar divorced (write the word) » ».....e _.._Date o/ rr ' '- -a Age ,, . .dears ... N1� s .. ..»»... Days Birthplace - use of Deatht'r _».»»»»..._ _ . - Certificate was signed by.... ex7 - .. 4rT `(»_...... ...,_ ... ... ..., M.D. Address____.—.... ._. . i = a of Burial (or Removal)....... se- _._ be held,MI in later Cti body is� �Y �e _ Cemetery i - Date of �Buriai.: �14 (If is m be temporarily held,fill in spate later) - - The Ce� of Death containing the ove stated particulars, having been presented to rue, after ;c ful -exam na- tioik, 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 Itegistered Number* -� 4., and oil basis thereof I T�IiR1 BY GIi.4i�iT k RMIT �L1 ei , Gx, _`., (Address) ...».. ...»., .—..». ..._...to hold temporarily and.. ...inter._..... .......„....—the body. (rti�er or petaon ha charge of for se) ~in remove, otherwise dispose of fie how}) Da Y ,. sty I c Signed)..» L cal Regi ar._ �= 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 other regulations), unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required. 'F+: . . uv. .41 m ,.. N-0 anuw3 ., u aaaw0',- 0w.�.;„ woa t(� tq O si $-¢myo u� ago U•7 A a0a0 a03.. eC0e. gh �ow 'aO.•.. , .a� . > qeqiy . 1►. aw s be"M ..rO A f i 0V« ,�, A a~ a • . 0 a .y I.. a � p a © i y >>.••. .. i. . :4 N.U. N 43` 0 .�. a v W.0 0 .a u w «. R • .. 0.g =-4c 8 .co 0ao 0.Syvv'� e-4. lat `dig." 001� 1 •' w w.4•r �" iir�,.0'0�i 0 O. w0 01 u V a0a ".. o c0 1." O p° b'_v O ' 16 444 68 r W' >6-uvui..== ,0 .0q.. w.o0v :Ou 0.+y .. F u -7„ g.. �t. ,ugr'0G uO '0�' t� CS0. C.... O` Q .< ,a, O b w>,u to u... 0.... V, a~ b0 m. b°>,> d y�... 0.j 'g 0 ... > �. a Q m .0w 'O >,.0gu... •E8a^ - NaEa. °' aa:. ,w., Oar 0.0y„u , 2'"Xlu 10 " - rs*8' LFiI p, Ui_i,°q�:o. � t7 Eli ss'v+'�y t. •u C" �t �" u war o•O V IS 0 M M,.. 0^0 w r% U 0 C wa oAc, o o O i.sv a ti� aro• : -. _ ..:estiw• •"'.4 p,a, 0,.....aU v s~ 1,� 'E p to .34 ," � 5 Q F..1 "�i 01.0 0..~� y V v ar.Q OM 0 1.1'D 1 _>p t3 SkCi c ..... y 0, _ A tv 01 a 11 emu'',, too F O 'J' 6 (�,u 2 t)4J m.4 O g cyr *. m l ;a. �" CL�+" m a 4.) +•.yy p .0 - N0.4`� yi.'g�. 12 vs °i'+i-. �+,, Y 'O•M O,eO+ar was> (a.., a) ::L'. _ N� .� i# ..-.� '�;._ >t ,.O.w O �o r,A.u 2 u ,•!(. . y .q.cltg .ii ., •s��,..'C) �»r,. u y e4i Ep0 -5.. a_g R W.7� Q' 4 - �ii it, ..s~ i s +�•. {,. O A Y 0 •,'�-+ i7 L+ N{�+i i 0 .7..,�*rr p lC•+ gtip. 7i, -sy o..4 .0 � v � N•1� V V°0.7 ii�i tr is 0 'it 4�� Li '�"� V + # t A' �'. 3. m y a:w O @^• u.51 4r - u. `fit v. ,. 'C! .c7 •A O ^a 4 u y a 'g.. u p�O. �3 O _ Lam* G �y P:. ... v>? " i ,=. y.. "•g:. ,0 1,. C„ _U w .. V^ fey•ly y• 4U, y rTi NR"++'-i&. • rr s �+... O '� m O. -d u" Ste- Z►y :-: P. > a•`3 w'- d.:aa �v•2 v .a 4 53, -a►- °a,,, t� �' w- -a _.vpr E+ $b.a" O,,,, >v ar a,.iy .+'�� > c.•'� ,.V va :V a Q.`4, r„_ ?.• �t at, m cd' 4. R,. e w ns.., ^ O -o, _ a.0 ri .0 ,g'0.. t0 c . as H p z i 0 w v m litUPil1 a . BV i �i F O°mr. .4:0 E,►N.,Ow.� f+Tj A awa.SF t7i90 u P i a4y 0 '1a . 08 a0Za3A� w a: ..... ,p �� o * * -�,$ ct#.14, n«r�.c �, ,,t �t. p ' y.• _..�. 'u•5o.., t�.O .'+•i k aS O ) 4. w c.er O 45'- `r"m,..,b -4' .. i ' H a.iiL; ; :..s 'b t o �... 4sa�. camW O.. Oe u �' y, s..O.ra•'":L. aJ a ufl-...w u it b W ed 1a a O O. ." 1 2-: /�ti (•a� 1 gH- '.,g g.0''h) .G A.. ` 8 Y.- Q. `.'" .' ai° s..a' 6... g^-... ,-w c�'a-u.y M y€ al w rA G� g >p+ � c '. i+�OyO.a°�y.gD �. s. ,, ar�,,1i1Iij1 p i0143r+ 4I1iiiDi 0 _3! gI o •1.a ate 04-,t2 giiti 4M y �.ga .+ h 4 b_4 r_, ar w u i+ u .1c g m u vi >1 m1 .. a,.g.a : 1 o a vqir it m t'`. A .. Rg Q 0 . w' . 'tit_ .:g 0�w•"' .1..,... ..ale :« .4 A s,.e+ q+°'. o.OA�'a� '«:3u elt `+pAyutiy. " $ti• ` �C,i:" e:ar' � >O'+i� "`a.g l%p O �•O..'+m 0.5 w 3 O"4.3 :4 °ar ca' . G1 iw !! O O w , w O .00 a rri •g .m 0 ".1