Legault, Joseph Form VS.61. 10-21-37-25,000(17-8459)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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. Re : tare o. ,Q..-_ .-__._._
Dist. Nok.Qa County G%i. TownVillage .1.+31'
or Cit If city,give street address)
Name of deceased ,.. .... ..
//II ingl , married, wid d,
Sex ' ..Color. .. .4r divorced (write word)...1� /...Date of ea `%/ 19.>
Age V 2. .Y rs 1f on s ( 7.Day rthplace�
Cause of Death.... ... .... j 4
Certificate was signed , %.6 . M.D. ,
Address
Place of Buri.,' or Removal).. ... .. ,. .:.nit.1 .�.. sP
(If body is to be -,.,orari el fill n ce later) �`}
Cemetery.. �/ e of Burial RP-
(If body 1s to be temporarily held, 11 in space later)
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have ccepted the same for gistration, have recorded it in my L cal Record with the above stated Registered
Nu , add on e b is of I HEREBY GRANT A PERM /�G� �,�
to....
(N Address)
the to hold tempor •!^ry and the body.
(UEd r or person havin charg of pee) :!.. ove,orerwil o![s to wl)
Dated K f 19. (Signed) i
ocal Registrar
This Permit is sufficient for the Removal (and Interment or Cremation a body any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Tr sit Permit (VS No. 62) is required.
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