Tremblay, Lewis ,
F.}rm VS.61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Pr 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. Regiateredoc.., +!r
Town
Dist. No... 4 ...Count
6r eity (If cit3, give street address)
Name of deceased y
. ... Li� -+?.-•tom-' ..�.���r��.�.t.Z.A... ,
,#,
�`�� ' 'ng1e, married, widowed,
Sex 4,.Color.a 3 divorced (write the word E;,-.. , Date of D eat • 1.. ..... .....19.W
Age j.' Year Months // Da s Birthplace �..o ... :..
Cause of Death - , ., - Air.
Certificate was signed by / ., M.D.
,�r - -
Address i . !...... :.. .. ::—
Place of Burial (or Removal) .. ..., ... . 4'
(If body is to be tempor 'y he 1. spa later) // �,`/�
Cemetery Date of Burials! .:../. 19.�!/
(If body is to be emporarily held, 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 accept d the same fo -gistrat'.n, have recorded it in my Local Record with the above stated Registered
Number, on the bash: t - if I :REBY GRANT A PERMIT• h�
to yi� �... : es
N er', : 'dress)
the / - s ..to hold tempor • an �?-'..Air'
• the body.
ertaker or p rson a i charge of prom) r,remo• or other dis, toe wj
Dated . v7••/ • 19..(i .2
(Signed) -
al Registrar
This Permit is sufficient for the Removal (and Interments or Cremation) o a body any part of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Tr sit Permit (VS No. 62) is required,
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