Robillard, Mary rorm VS. 61. 8.16-3 5.50,000 (17-1423)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
E '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.
Dist. No. 1/4- -‘° I Registered No. c-Sr7
T�/ own 1 %i-c /1 *� 9Q,�� * cif,County �61/�,r- Village /� ° lam'' ,e �'
} or City (If city, give street address)
Name of deceased...A.P.,.,G „�'
Single, married, widowed, p 2�
Sex' Colortiviz �-- or divorced (write the word) 14:-'~ Date of Death �p� S 19 36
Age- .og.� Ye rs ,.� Mg�lths aZ Days Birthplace �''r 7Y�'-4-�....w.
Cause of Death . .. -,,
Certificate was signed by 2=4- • M.D.
Address '
Place of Burial or Removal) - � — -
(If body is to bet or y Id fill in space late f Cemetery... ... • Date of Burial &-c-. 6 19,3s
(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 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 theth above stated Registered Number,
and on t basis thereof E, GRANT A PERMIT l��'7 G
e) dress/
the l to hold temporaril the body.
persong g rt e) r ove, or o erwise [state how])
(Under er or Navin hae a of co
Dated fc.G�yleae - �ly 19..,.!f (Signed
Local 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 other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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