Bazinet, Frederick Form VS.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
ar 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 D
.Fa ABLE BLACK INK. O> Registered No --, Z—G
Town
Dist. No.cQ.�Count V' e .
,r (t)...sr..fr.:eif4
i ,, If y,give street address)
Name of deceased ... .. .. .. . ... .
-ree.., 0 .
,t Single, marrkd, widowed,
Sex%�26 olor..kN'L..or divorced (write the word).. ....... ..... ... .. .Date o D th.... ...... 2 19. .o
Age ° Y rs .. ..... onths ...�.�....D ys, Birthpla .. . .. ..
Cause of Death 1r
‘ ,
Certificate was signed by •.; _ .D
Address ,
,, y �,. c
Place of Buria e or Removal) � �-�(�- ._��j,/ " s 1
(If body is to be t•.::::rari el i pace later) p
Cemetery... e, Date of Burial tom.- ...D 19Ve
(If body is to be temporarily hel 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 cepted the same for re ' tration, have recorded it in my L Record wit he above
stated Registered
Num rp and on e b is then I HEREBY GRANT A PERM Ca ✓
t0.. ... ... �: (Addr
ess)
ss)
the to hold tempor • y and the body.. ,
(Undert- if r .•_,;on :awing chargeg�q� rpse) er,remo e,or r s e of stat owl)
Dated `.:'. ' ` 19..`f..0 (Signed)
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cre a ion) f a bo to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier,in which case a ransit Permit (VS No. 62) is required.
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