Blanchard, Mary Form VS.Si. 10-21-37-25,000(17-3409)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
S' 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. Registered No......_...__....___
Town
Dist. Ng32-10` County Village
(If sit ,give set sa)
Name of deceased
Sing , married, dowed, c
Sex Color or d orced (write the word) .. �,...-...YDate of Death If 19`�a
Age Years Months. .. Days irthpl ce
Cause of Death •
Certificate was signed by M.D.
Address
Place of Burial (or Removal) i .
(If body is to be temporarily hel 11 a 1 er) eb ~
Cemetery Da e of Burial 19
(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 exami-
nation, the same appearin: to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same • registration, have recorded it in my Local Record with the above stated Registered
Number, a n b- eof I HEREBY GRANT A PERMIT oearze___e_<
the - . \� / ) r to hold tempora • nd �G„�'�resa) the body.
(Und - '•r or ere .,. •ng charge of corpse) I ter rem ve,or of dispo [ tate howl)
Dated ' ' 19 (Signed)
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a b dy 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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