Dumont, Theresa form VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tar 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. I...Z.--
Town
Dist. No.5.601, County Warren. Village. G1.ene. .F.e.1.1.8...Hosp.i.tai
or City (If city,give street address)
Name of deceased Theresa Marie Dumont
Single, married, widowed,
sex FemaleColoinwhi te or divorced (write the word) Single Date of Death August 30 1939
Age ———— Yeaf —————— Months,HrS•47-MrmyCn-s Birthplace Glens Fctligt, .N.,t y..
Cause of Death Prematuri ty
Certificate was signed by Dr.. .zeivil :rAta M.D.
Address
Place of Burial (or Removal) QUAgatetbilrY.g.. .Na.. .Y.tt
(If body is to be temporarily held,fill in space later)
Cemetery b t 4, Alphopstis Qemetery Date of Burial Aug* 50 19 39
(If body is to be temporarily held,till 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 Loren
(Name) (Address)
the Undertaker to hold temporaril ter the body.
(INdertaker kr.person having charge of corpse) r,re r rwise dispose of[state how])
Dated A II&• °U2 19...39. (Signed)
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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