Lapointe, John Form VS.a NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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-._...,3._4___._._
Dist. No...1.4 e/ County aL//- .-.._. \cll.,be.. d.,_..
/7 TCi tit city,give street address)
Name of deceased Amite_ l.I. .. .� Ate
Sex-Si- n D ,Single, married, wido e,5'd, psj.„77 .o y
idt4Color=-for divorced (write the word)../'(.41. LR.C.,,<rS..Date ofZ eath.�(»[P...4�• ���R
Age ti Y trs I Months a ...... ....Days Birthplace. �fnl4caswe �p+
Cause of Death... . ... � ' ,r /e
r . .
Certificate was signed /1 f Asa/
>lim � v.. M.D.
Address . .. . . .Place of Burial (or Removal) � tce0 /lie
(If body Is to be or 1 held, it in space later)
Cemete tr<r[QaC kQ/.. Date of Burial ./.. 19.. 1
or body to a temporar held.MI In space later)
The Certificate of Death containing the above stated par iculars, having been presented to me, aft r careful exami-
nation, the same appearing to he 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 MI- ,quid on the has* there I HEREBY GRANT A PER
to ,mac tr�.� y �
�, Xl�.a,.teeI a.
(2 me , (Address)
the to hold temporarilyy��a d the body.
(Oa a ke or?Too having chars mrpae) %� (ln ��.r otti dowse of(state how))
Dated ,�• t 19 Y f (Signed) �ld �. y . :.
•/'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
.......,.... ... ..,L.. ._.,..1..:___ .,..1........,..,..yl. A ..a ..............t.. .. ...I:.1. .-.. . T....:. p.....:s /Va W.. fit .. ......:...t
rIti SR0 w =.+ 5°'na`=y.v>; i °.EVVw»0,0 n r"s_n TR 'n 0 n n `'.$ .75.0.s ,-- GT-Iv' 3•.." p
_D3 R3.a Sir an `n6G0-aa E5£n55�ir e�n g n 3_.47-9, t'io 5.n,1n 3 ^ O t < n .1wqq n m
XI• et N..5 �'.p6 6w �R Oww ° »D nS50 W�Wy n ' ' _ � r"-rO S96. W r^O .Z7zn S= °. 0
n yy • S n OdC oco-E.= n-1^ _..4, en,
,N'G'w _: o'V E S OO O•
R a-g e1 s1 .4 .N n la to.Ste...' � O_-.n OO wq "" O JJ G^ N _.a.O.-.w v 0J
n m wsw ~^ w = 4 • m ^ •
n < • CA:K=X S.oRn >3, -.33.• , � �, i+ � 3o •2n a�� ° �' g< a E.n : 3o•nnd^g R1 a".c.�.' :�(+�l
70?O rw� n5-6 " 3 "r=oet nio -. .Tope z......neb g5=' -y = n .c,=Ao.-1 p oi0a :t rom
prz n •-•n° ^aF S=-3w � �?� a$ 'R g' v. �y ., nN ^ 5n'T�,-ao.. , 0.. � or .R7.4
al. 111II!II1}HTh
� = � " :: =ta0 Z • F- 41 w ^ w ^ .. y, » _.» a, s mm° Nr6dC UutTIHI
n�-' v3o,,7:nE3To3Rce ^r+ �a„�, tilL!
4 Eo`�' 7 ' cr, ,N0 ° � et n „, y�T,c'e aN° - S'•'o' " a w ^--, Fnwo c$O<Or.fO .+ .o n ° =•ud_ -S a»„ : O�� 70n ' oOR ,4g,n yS'�wnl-rna n w Ow ^''�7 C H�.H n � n�, a � � o = � �'a Lw Sow 7..no r]= --• 'wR O _ n'2 " C1.o n-.4o n•O0 " 1'8 D.S n <.'W•. n .°_C 0 nO P' a M l .1.. ? is -I x
T. =▪ �� ^".c< cov ^ 03.ncn• ° �Rw� ?;R c3u`�»'�'n c�.a8'e3'Sj .awrg,' 7 =.o cr " � ° OTO
Zaaz
=•,n o' cy 'mn•. O.- ' oS.•n A'" r.• :••0 o°.C•
JOS�4ge•wwSm R� 2.� '=i..� ra ,,,e =� ♦ ton
ZO
v0 r E °,wo <_.pwN - an _ n 4 .1W n»., ar' °.�" = .a " a^ SN ., $ e� &rY ^r �'300 , ^f� •
°^SSA 3.�,R.'nww y° ' n•'. ° '•' a'Ln'* 9e' • 9omno'R --- -- 7. -n!.Pn 0 - '.i12�
D -*Ica o ..+ 5 G'»'n .ig rj ,Arun n�'-.o • = -3
r sti
• cm FE .ttiIt:tLrta1.
5• - =.5 " o 5•-na ° n. ,•<o c"'� " P° »a .nnv? ... -5n an`aa^Ro ••, - ^ S 3ar�agqa� rr, RoFB.RRna E.5� 3 --.2R3a', i�R tf.a ►. --o •C.:. �/•
o'n 04 i ^ nw SR•d ; R a a 2 as o :•nda 3.3'0'n• n, 07 sR5= = n S^ cs-S.y,. • 0- H y = n lamZ
= °ram _ n ^"o ° Ono 0r°'g •" ce, ° ov „'4c 5-9,,vN^o�'"_,nec;?n.Fr. =•aN'aTn iyn�rc_ Hz
s is � 3o8 „°ga�. a., -8E :1inii
- ou " a ', $,'o,�6D QQ < Hwu -_.nQ _7^ . � c _.POS < ..,< ' c^ cLr s-�°o --5H- .8 N.- " n o'T wpon ,.a0/, .1o _.^ � � Zo ^ On ague= �n^�wnon3-53n EZ•}ii6lifGhjco' o Xa•"O "An
▪e3c .-'o ^c=.a" -•^'E o.w'0g pj;iH
oi:HilRbI!4Li%;
,'0 ` 7.n Oa E.-. 4 p�°. w F R < a ga =oy m° �A '( n = R O.� § o.R'� •w.•a.'A? yam.. � m