Guyette, Frank Form vs.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
12r 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-
Dist. No 101 County Albany Villaswn lbany
or CI (I!city,give street address)
Name of deceased ik.A ,..
t t k Single, married, widowed,
•
Sex `_,—>,' Oolor>J'- or divorced (w -the word) D f Dea __ 1
Age '. 1 ..Months. . 0\.......Days •.irthplace.. . t
Cause of Death -
Certificate was signed •
— , M.D.
Address — . ...�.',
Place of Burial (o Remova . 1441611E. ---V-+ .•
(If body is to be temp y eld, s ace late * r �4.
Cemetery Date of Buri ,. ‘C:11, 10
1
(I!body is to be temper held,fill in space )
The Certificate of Death containing the above stated particulars, having been presented to m er careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND TISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registra' have recorded it in my Record with the above stated Registered
Number,tZNtt,e basis th fI 1 Y GRANT A PERM4:1Artto .
to �1.,.�Na .. C(.—.,Af. reefs)(Name)
the. to hold or nd
n rtaker or person tag;
charge o!corpse) (Inter,remove,or spine [state h ]
Dated.. ...... 19 ' . (Signed) ...
�) Local R gietrar
This Permit is s.A,'ent for the Remo (and Interment or Creition) of B y to any part of the State (subject to local
cemetery or other regu tions),unless remotions by common carrier,in which case Transit Permit (VS No. 62) is required.
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