St Guay, Fed 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, LEGIBLY WRII)N IN DURABLE BLACK INK.
Dist. No ` �` .. ....__. / Registered No.....,,a
Town % �i�,/ �'-"`_- LL t�
County U Village \T L
or City (If city, give street address)
Name of deceased.... vFi
�1 i 'ingle, married, dower, .
Sex `�Clc olor�� � ivorced (writ- the word) y • 'Date of Death /J..19 3
Age Years Months 7• D tvs Birthplace •
Cause of Death .. .
...Certificate was sigt d w.. -- .... . �� M.D.
Address
Place of Burial (or Removal) t��
(If body is to be tempo r y geld, fill i spty 101) �+• p �j
Cemetery o � J'moo Date of Burial / ./ 19 Q
(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 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,
�,B and on the asis thereof I Y�i�PERMIT ��%�'e��l:.(��
(Name) (Address)
the to hold temporarily nd the body.
(Und etaker or person haVfig char a of co Inter, remove, othywise ose of [it sr])Dated1/..L...44 19..J.s (Signed) ."/ f/ •
Local Registrar
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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