LeDeaux, George Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
t 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...,2.0.—
Town �4 t<a4 '13Dist. No 5�'`i County.... 4d!a2.t-�,. Village.,rG1{,�s.e /y/�/
,P� It
y (If ell). give street nUtl Mae)
•
Name of deceased Ca .G cir
�jj —/ / Single, arried, widowed,
Sex.:%.. .[Color...!(/ r'divorced (write the word) Date of I) th ..6i 19.n..
Age.....63 Years MoAils.... Z..' ...Days thplace....l��G �
Cause of Death .-..� .....
Certificate was signed by ?Cwd � M.D.
Address
uria �1` ?
Place of Burial Remo al) In spa a rote /,1
•
(It body la to bet rKas • } fn epnce later) /
Cemetery... / .. .1. 1/,- Date of Burial.. `1rff 4(1 19..
(If body Is to be temporar r held, Bil In space later) /
The Certificate of Death containing the above stated particulars, having been pres Arad to me, after careful exami-
nation, the salhe 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, ou *, is ereof I HEREBY GRANT A PERMCI�a�//f ,e
to . . 6,L!(' ." ... a .. - _ ;�.�,Y✓..Tjj (Address)
the.... . to hbieht,Nuorarily and .. the body.
ay and
(tin or pe of rIng charge of 52pae) ([n[eer, �'o' , Ie of{state bow))
Dated.... .. /• 19...4re (Signed 1 t,,: L+ '.. .. ... ..
Loral Itegldrrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local
_._...-. ... .sh.. ......l.s:-....1 „ni... .e,nnml is lsv r„n,,.,nn riot-sin ,,. wk7.), rats TrsnsIt Permit (VS Wet. 621 ,s insentient
t^Ho , .., ow ¢.w g a,n<^ _.tncq ^E.g :^^ n r 0 n P'R o "'-n .'3 `-.oP-^,r E:3 -3F OTHtn 3'^^ O
-2: ^n7 " � LP -to� s.^r, 3 co,o•o•' n ^T_.nThTT4 co, --nn'$ ,nmow0-Eg. ., co ;? � -c ;dr,CjI r it IrI
pT n rn ,•°,.so5oc 74 naa�R �o�^'E''gNaon4otan'-ng .1inifr-n'an-4•:^. 0^ reecrei o, a'; Aze ° $v. :. O
8.'�++11� m nwwagoo wSt:�^ • ^ ^ „ n..c a c'P R,�r' :._._oo°�.n ow o S�Cm a e O
,i_X EE _^ no o �> > ww ron ^ . nn nos^ eb V < GnL 5n • m P _C�o •" .'9
PQ?O Pm3gt. ?:" ^ 3awonr 3g ^$ -, a. .-o g. nnTS_ atmat w8g g .'S' n.k] m-{-La'. ' ^p to
QrZn -»1-.^ IB•=-3wn o•.'cac.!RoO.:o d'v •. e ., n— at
a3 .. ag . rj.t. an x3
• , or nz„ c0-, g a awnr z-'RG.yn?j ' Agngawyn,.�LR _a w^ -.03w, -• E.-a • R1I+7
or :... o• S.oc2 y. .5, o. n.=o n '- •. _^ ^ n^.o aoda- w 5'E o3n6T_. a'"v3.'r'• •°. : y..w' .r 7,,
e ,y o :1 '4 o n o•=• Ea3 caw '^ 0� 30 ^• E n� R-.- a on :.o_ trj33 .•. A
aynC doc ,.r 00 °•� e�; ' n^w --,o 5c w•n'N•o w S:c ^ wo gSTg•'�'m _T^ y to
+'m=Z ••'• � n-.0 •-• n.3'c 0 Rog r, 0.rai n..= ^Tno•1Pw €E-g , go .cc -•Er Oo O33 nr.i)
e pre m n oo on ' z" A. .n nonX n _ ,rE as-^n &0 . w .7^ mo • ^ w
; "'F^'•I ns0e ^oz'FC o.� n3n:.R ,^. tIEOEt
° jiflii ;E '
a- aw ^^ ' aLit
y° "' � 2'I�7
0 cm
�Om �-°, - ; nnoo ril xfl !o
e ��,,77 � o _. �' o ., ^ o to1 . . o-g � _wR Zn y 'SO
_70 a E _, ew-n _.n ogo n .�A n^ ' a� 0 c..Bn u' _.,.. r. , eG3 f Q,.). "e �-1r n Y
$MT.,*"5- :2 wa� oe' 3r annE.e3PK = owooc 0 '''S ,. ^ aw o y[' I ^ m e �. �� �z'.O
o ZZT n es Pyou ; ^n Ixn"� 0o �'e adrw E.n on n0 C,rEn? n-a,a goc.''^n aU) I ; m{nsso• r _ m as
e •• 'r n � 3n ^fir n = ' n nnn RS F6 El n3•n5�2'a - Ag o 'e 3t �, c 3 rn_ .A
' 70
"• - ao -^; ^ on Pr -w " "03 � ,. $'-I *1 E.sn VP. . 0 - acn•, E . ..I it" n ,a. , a CA
0 TP1F a0 ^a r,...° aa.r,^.to nn o =.33.•n. ^ ?m •. =.'C ..^ -. O E.::: n '� CF'a. V1 . H. -.4 .'^1. .� O.�O
Dean ,, -, ^ SA_nn •, o ' ^ up o __ndr ---- 3Ro,.f', nane3.-ar QLn ^a ,,,I w an h7 n7x
Isar =.n ;^ noon"o3•'•� '.. - 000w'� coT^ 'n ^. 6 -.0- < w g•'.NCram" n*_Frn '�..
3.6r"• r � ,o. 7o n ' wo -, zip nu?:5:42; w' a^ ow ^'5n u n3nFo mte ny °'H-.s'• -* yz
-. R. w .o. ,.cnnn ?n .�3: r-.*y2etno^ o c. gc _.c ' n 'C < Y^ -' a5c.r 2^eME n 1 OA
Tq. rz "wn=r o$ ec.c , ,�'• on g3$R w ^'• s, -in u0, 0 sig S•�(1cy'3 go - 0.r. o p "An
r,C� 3R �� nnG n o r-•-.g.o.'-• T$,�,a&•'c nR n .-id' 3 ^ �0. 0'.-0,^, o., E,�' 2cn >
tv
_ •N -.w_ F_� F <
Xi
-o3Z Eoo.na= f� o' a nT»^ y 3 NonwR4 ^ ^ vG.-r.! rn -'c 7ir Z In
n 0 o O r .. .E.•. -• .• , 7d.-.... s u< 3 ^ n E'n P :.o g.3 'rn ^ O f. r! ID O
e a$r naT < dG
4Ao �S•m5K3 -'�'-"2'ao•o n _.a =a o':.3• vo E'$`w_z a°o=° Oaso� Rg w9. T X I '*f
m.,, �n _or , n� u. ou . •c •. n -. , —noow •c •, S- oa3'w4wb'-...q'DaS5 .. . o