Tremblay, Emelia Form VS.sL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar 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 CERTIFI A E OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No..
Town C - /
Dist. No.tT6 0/County Village al g
or City (If city,giv t address)
Name •f deceased -g-' 't.. '
�/, Single, married, widowed,
g
Sex. •. . • _.i:r.. .. ... ....or divorc ad (write the word) . ate of �,19c ..y
Ag �C .Y rs Months l. ays iBi thplace .
Ca•se of Death
Certificate was signed by tel a ` M. .1
?.dd ress `l►� - . -c - ..� . /
Place •f Burial/for emoval .. -,�
(11 bod7 is to be po y held a la
Cemetery..: ,, Date of Burial:. .. . -,2 7 193
(If body is to be temporarily held,fill in ace 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 a ted the same for re ' tion, have recorded it in my L Record with the abovestated Registered
Nu d car the ' ereo EREB' GRANT A PERMIT ga /
to ..
to hold tempora ' d dress)
the .. . .. .. ...... .... .. .. body.
r or penhavyls charge g comp ) rwl di of[sta owl)
Dated c�!.(Q19... Y (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or em n) of a y to any part of the State (subject to local
cemetery or other sego:::ions),unless removal is by common carrier,in hich case Transit Permit (VS No. 62) is required,
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