Beaudet, Delima Form VS. 61. 8.16.35.50,000 (17.1423)
NEW YORK STATE DEPARTMENT OFEA HEALTH
OFFICIAL BURIAL (OR REMOVAL) P
fir 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 CERTIFICATEOF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. T d
Registered No.....1 r
Dist. No •••• / Town � ' Jj
or City '
County VillageZ (If city, give street address)
X
Name •f deceased....‘igo-. "` "" f
I Ingle, married, widowed, � �� Date of each 1 f 19..
i , r divorced (write the word).
Sex..� ..Color.. . .-- Birthplace _'�•
Age 4f Ye s U Months Z Days
Cause of Death .— I ,. M,D
Certificate was signed by...... .
r,._, „ �i' '�j
Address r!i *7 ram'- 2 ul= / '/ ` 7-
Place of Burial or Removal).. �""t•• • t d 1 19� 411
(If body is to be� / ter' Id, fi in space later) ��..
`� Date of Burial
Cemetery :. ..._:. .. .. ..P..:�x+':: aimth-1-7
. ... . .....
(If body is to be temporarily eld, fill in space later)
The Certificate of Death containing the above stated particulars,
having been presented to me, after careful examina-
tion, the appearing be COMPLETE, it in my LRECT, ocal Record SATISFACTORY
the above stated Registered Number,
I have accepted the same for registration, have
and on the/basis thereof I HER Y RANT A PERMIT e) fJ ,-
to _(Address
to hold temporarily a ��+�'
- the body.
the ..KZ' ... . er; remove, or of ' dispose of [state how])
(Undeker or pe on having charge of (Signed) -'�
f � '•. Local RegistrarDated „Zell of the State (subject to local cemetery
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part
or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
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