Hubert, Augustin NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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, LEGIIBLY WRITTEN IN DURABLE BLACK INK.
Dist. No.�Y..�,i-- Registered No
Town,
County 4 ,..,, ,, Village
(If city, ve street address)
�
N e of deceased
o Single,married,widowed,
S ! .. or divorced (write the ord��! 2 _Date of th...,� �T�s _.....193
Age jYears Months a Days irthplace..r���%- .L..... ..
Cause of Death _. .. ............._..
Certificate was signed by _. . M. D.
Address _..
Place of Burial (o R moval) ,,. _ ... .. ...._............_....
(If body is to be tern it eld, fill in sp e later _
Cemetery _ Date of Burial - �5 19j
W body is to be to orarily held, fill in pace 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 a basis thereof I REBY GRANT A
PERMIT�1
... . . .. .. .. 2,4.. ... ...
ame) Address)
the to hold temporarily d ....._......._._...._...........the body.
( rtaker r pe s having charge o.&cre) r, remove, or ofS wise] • se of [state howl).
Dated.... 19 33 (Signed) 1W ��'••! ..
Local Registra
This Permit is sufficient for the Removal (and Interment or Cremation) of 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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