Brunelle, Roselda Forts WS 61. 1.23-5 .2$,000(17-5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
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.' .7 2-- 9' Registered No.
'' Town
County L11 1/4-1 . 1 e
•
� � ((�� of City 1 (If city,give street address)
Name of deceased RO-ol.
/� �'�•1\J Single,married,widowed, n
Sex "i Color Y — i or divorced (write the word) r--� • Dat o Death./0-�-t 3 0 19.t0 4?
Age Years Months D Birthplaces - a ...,,
Cause of Death
Certificate was signed by IV "CD M.D.
Address `
Place of Burial (or Removal) 5� a
(If body is to be temporarily held,fil 'race la er
Cemetery ��I- _._ _.. Date of Burial .. 19..
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing e above stated particulars, having been presented to e, 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 above stated Registered Number,
and
,,on,the Oasis thereof EREBY GRANT A PERMITto. p n r;
(Name) (Address)
the _.... to hold temporaril and .....1`. .S....AA..... ...._..... _the body.
ndertaker or person having charge of corpse) (Into remove,o thervyt s-dispose of[state ho ]).
Dated Jf1 a.. ..._ .r....._... 19.... .4 (Signed) . - C, .... .. .t................
Local egistrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subj o 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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