Guyette, Arthur Form VS. 01.
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL)911F"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, LE J L WRITTEN IN DURABLE BLACK INK.
Dist. No.s;.J...6.6ie Regis red No......../I
Town ) / j
f
County . .... .... ... Village C. 7,1 - t
i (If city, give street address)
Name of deceased ........ .... /
Sex )y�, A, '' '' // Single, married, widowe ,
2-'... Color !rf.l.._. or divorced (write the % rd) Date o Death 'r&..,Z/ 19..7d
Age 7 Z....Years Months ....44...Days Birthplace .. �A..,G
ilii
Cause of Death .._ _ . _. ... •••.
—
Certificate was signed by M.D
Address ..... ./'. . .. ... .
Place of Burial (or Removal)
(If body is to betJ�9�orar}ig e . I in space late )
�.1. ..il.. - 6r7!(.r Date of Burial �---e-c.. �..7 19...3.E
Cemetery..
(If body is to be temporarily h . 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 on the basis thereof I HEREBY RANT A ERMIT
ZZyAddress) ,%
the.. ... dt ! to hold temporarily and the body.
(Undertaker or person having charge of corpse) nter, re v , or oth dispose of (state Low))
llated $ .6- 19. , (Signed) W� -atee-S /
Local Registrar
Thi ermit is sufficient for the Removal (and Interment.or Cremation) of a body to art 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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