Gaudette, Napoleon Form VS 61. 0.8-34-50,000 (17-7901) '`
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT 1
'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, LEGIBLYf7-S WRITTEN IN DURABLE BLACK INK.
Dist. No.J �/ Registered No.
1--Townn
CountyiP, 1` Village
or City (If city,give street address)
Name of deceased ...1./z .. ... .,-i"�
Single,married,widowed,
Sex 444" Color or divorced (write the word)..- . Date of D h.... .. � / ' 19 3
Age Z
/ Yeaj /.., - Months - ...Days Birthplace.. iti - =:� 9€- 'e
Cause of Death.. n.f,"Y' ' _
Certificate was signed by . .. , M.D.
`Z/G ,�,a�
Address ,,
Place of Burial (or Removal)
(If body is to be temporarily d 11 in spa la +
Cemetery ..f ig/� . _...... Date of Buria,J - �'t- .l2 19 3\
(If body is to be temporarily held,fill in space er) G'
The Certificate of Death containing the above-stated particulars, having been presented to me, after careful examina-
tion, 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 awe stated Registered Number,
took n bps tl}er�o�REBY GRANT A PERMIT / , _
(Address)
the to hold temporarily and the body.
d take or pets n axing charge d i ,corg ove,or of rwise dispose of[state how))
Dated... .. 19. e (Signed) ll1 �
Local Registrar
' -' his Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local cemetery,or of er ct ml}s), unless removal is by common carrier, in which case a Transit Permit (VS,,No. 62) is required.
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