Dumont, Fred Form VS.$L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Car This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No. 173
Town
Dist. No 5601 County Warren VillageBudeQls?...#1 YoI'4....0.14411e ra11$,....N....Y.
or City (If city,give street address)
Name of deceased Fred H. Dumont
Single, married, widowed,Sex...Male....Color W 3. married Qor divorced (write the word) Date of Death June 10 19 39
Age...4a. Years 8 Months 2 Days Birthplace Canada
Cause of DeathkaphyXi.a.ti.on...t.X'Q.CC►...S r.P.W. .U...ir.1.. u4 .,aOn Elver
Certificate was signed by Dr..a...H....Aa...aartd191.Qmew, Coroner M.D.
Address Glans.
Place .f Burial (or Removal) TAltn...o.f...Quaensb y.a...N.s....le
(If bod7 is to be temporarily held,fill in space later)
Cemetery .St.....AlIzhaxl.sua...C.emettary Date of Burial IT .iAR....U.s 19.39.
(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 exami-
nation, 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 on the basis thereof I HEREBY GRANT A PERMIT
to .Ha.rald.C.....S: atfArd 1.o.1`71S..F.e.11.e.e..N.....1*
((xx�) (Address)
the Undurt.altalF to hold tempora ' -� the body.
(Undertaker or person having Marge of corpse) I .ove,or .i. • disposeof state how ) y
p-' [ I
Dated �T.tl�l�...a.£ts 19...3.�. (Signed).. t.. ..
Local Registrar
This Permit is suf41-lent for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
cemetery or other regu...Lions),anle sa removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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