Bazinet, Mary HEALTH
poem VS. 61. 8.16-35-50,000 (17.1423) YORK STATE DEPARTMENT
A} PERMIT (To ,
NEWBURIAL (OR REM Registration District Pr
OFFICIAL BUR or Subregistrar) of the Primary
CERTIFICATE OF
Registrar (Deputy
gAI-11".--/ \\
This Permit can be signed only occurredb thea Local
after the FILING and acceptance of a CORRECT AND
Village, or City) in which the deathRegistered No
LEGIBLY WRITTEN IN DURABLE BLACK INK.
DEATH, •
0...... .................. give street address)
Dist. N �'kl')ttg'e••••••••••" (If city, g
............. .....
.............. ............
.................................. ........street
Count . ....... .. ....... .....
Date o Death... ..... ..................... ........191-�••
Sie, married, l..1..... ...... e
•
widowed, � �� .
Name of deceased....... . (write the word) !'�."�"u''............ .
... ... .. ................
Birthplace ...
... ............ ....
,.......Color....�••••••••••••Or divorced .....Days M.D.
........ ........................ .....
of Death..... . ...� . ... .. ..... .. / ....................._............ ....
Cause ... ... ........... .. ...,�..�' •'(�' '�-'� ...........................,....... .................. ..
Certificate was signe . . ........ .,....... . w................................................
...
Address....... ..
Place of to bBue (or Removal).sp ce• 1'4 Da e of Burial.......
arily fill' space 1 er) f
............ ............•••••• ••••'"""' ,. been presented to me, after careful Y LAW,
{If body is to be P •..•••• REQUIRED B
Cemetery... ... , particulars, having AS REQ
the above stated p AND SATISFACTORY Registered Number
(If body is to be temporarily held, fill ' space later) CORRECT
The Certificate of Death containing COMPLETE, Local Record with the above stated RQS /
toina-
e i have recorded it in my
' the same appearing ��� � �
HE GRANT A PERMIT / ........... ................. ...
I have accepted the same for registration, I l ddress) the body.
and o e basis thereo
..........
... ...... .
N temporarily and............... of ...body.
....
....•••••• nter, ove
i dispose of lsta
.........................to hold
to o
�! • ""� Local
(/ . ... .... r of co se j�, „ Registrar tile....d .ertak Per n having c a y (Signed (subject to local cemetery
t, f� (Signed). � •• part of the State
r�,,...19.. .... to any 62) is required.
Dated ... . ..............
..rt..
common carrier, in which case a Transit Permit (VS No.
Permit is sufficient for the Removal (and Interment or Cremation) of a body
This unless removal her regulations),
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