Lebrun, Bernadette Form VS 61. 6.8.3440,000 (17.7901) •
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dar-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
,{+ mTTEN IN DURABLE BLACK INK.
Dig. Noll '‘1/ Registered No
Town
County_. L /._ .: : ......_............_........._................_._._..... ---Village... . ..._ . _:_ �O City (u ar.ei. str L — ._._._. ..........._.._...._...._._._._
address)
Name of deceased.. :_._.
" gle,married,widowed, - y
Sex.__........._._Color. r divorced (write the word).. -..Dat Dea L. _._----.19.37
g ..Days Birthplace ..A e__ Years__-.._lQ_..\fo ths__...._._L _...._ ce-�_._......_---- ..___.___..
Causeof Death._.-...-__._______.-_ 1rlrr�� _,xI �� . .._ .._.._.... .. ._.....__._ _..__.____.___.....__._...._.__._.
Certificate was signed by _ .rhCt.k ............ .... y`_4-. ._...cx,-r -r.. .,..... . , M.D.
Address._._._..._ .__.._...-. a„ ..
Place of Burial (or Removal)__._._._._O2-G .— -Rt�
(If body is to be temporarily ld,fi in la r) /7. �j
Cemetery__.___... ) _._ CAM _._Date of Burial. . ___.__2-_______19.si
(If body is to be temporarily held,fill ins cc later)
The Certificate of Death containing the above stated particulars, having been pr nted 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 on?th basis thereoff HEREBY GRANT A PERMIT si
to._.__. 1._._........__..._CLatati :--t:-------.....__._._ __ L._.._�2' :_.._._..___,
�] sxame) �n tare,,)
the.__'iq-^Z l i .4CIC1� to hold temporarily a; ' .. -2../C-1 .__._... the body.
(Undertaker or n having charge dcio r (bore emor . ra•ise dispose of(state how)).
Date .._.. . 19.._6. (Signed). _.>__._. &a—<_.____
g )..
t�nv—������y Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of # body to any part of the State (subject to local cemetery
or other regulations), unless removal is by common carrier, in which care a Trans Permit (VS No. 62) is required.
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