Hamel, Andre Form VS 61. 6-8-34-50,000 (17.7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
DV"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'Nrelif7 Registered No.
f�r Town
County �,f/Y C%vl/.11..liri... - Village
or City (If city,give street address)
Name of deceased
mgle,married,widowed,
Sex 1424 Color.aefAr divorced (write the word).......... Date of Death / 19...3
C
Age L 7 Years 0 Months 1..4 Days - Birthplace et
-
Cause of Death e ... Ci y •-.
Certificate was signed by ( .e/�" ea-15!�, , M.D.
Address "7. X.--e-4, .. ....... '1...-Tr
Place of Burial (or Removal)... • �^ •=*+ V 19�L
/
(If body is to be temporarily held,fill in space later) ��ry7
Cemetery Date of Bur al
(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 the above stated Registered Number,
and o the basis thereof I HEREBY GRANT A PERMIT ��
Name) �,ess�
the. . . to hold tempos and body.
th
Un rtaket person hav'ng charge of.fo se) (Inte r:• ove,or• ise dispos-of[state how]
Dated. .... .� 191..1. (Signed)..
- ..cal Registrar
Thi Permit is sufficient for the Removal (and Interment or Cremation) o 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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