Lamoureux, Philip Form vs.INCA NEW YORK STATE DEPARTMENT OF HEALTH i
,' OFFICIAL BURIAL (OR REMOVAL) PERMIT 4.-_____--::
U!This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,..
Vi e, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERT LATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Fegiste ttoto._.269 .
Town
Dist. No *O?Q3...County WaI I'en Village.B.O...blame.alm...St...,G1ans..Talls• N•,•••Y
or City (If city,give street address)
Name of deceased....Pb 1.lip...Lamoureux
Single, married, widowed, r
Sex M410...Color..i11:1.0.or divorced (write the word).xacaried Date of Death Oct, 6, 19. .9..
Age.. .6.6 Years 1, J D X
d: Months Days Birthplace �l.sS4?�1:��,�,l�.p�`�:..... .a
Cause of Death...Earelya, ,B... g]..tanzm3...yeazs
Certifacate__was_signed by Mr... ..U,..;.,....ii}3,'3t.iland __ _M.D. •
Address 01.e aS...rF is :. i....X —
Place of Burial (or Removal) We,§I Gl a,g,..Pall o:,.li..... a
(If body is to be temporarily held,fill in space later)
Cemetery.....S.t.....AlphOrtSus...C.erae tery Date of Burial Oct. 9 a 19. 9..
(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 Lion.e1...J.,..�B:oivin. G alas...F'$�(Adonis)
.
Name
the Undertak old temporaril the body..
(Undertaker or person char e o !e7 I ;,, r 9r oth spore of[state how])
rQC ' • ri,, ( )... f�
Dated Qti.t.....:6. ..- � ..���, ,a S� d
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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