Normandin, Claire Form VS.61. 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.
��jj�� d ,ecu...„,..2...,._<ji
Dist. No � 0 County �'l...(!.. . ... .... Town Village.-� O
/,( _ 1 pt City (If city,give street,address)
Name of deceased (/'� 7
Single, married, widowed, '
Sex. -4 Color.�i'�1.7!( or divorced (write the word). ..Date of e h sz1�.19.. ..�
Ag Ye — Mont s .. ...Days irthplace. ... -f
Cau of Death • — "
Certificate was signed by.....:..
M.D.
Address !
... ...
Place of Burial (s. ' -moval) ..2. . ..... star..- r
(If body is to be tempra {y he 11 (s ce er) J
Cemetery Date of Burial ..4•21 ,/
(If body is to be temporarily held, fill I pace 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 ac epted the same fur registration, have recorded it in my Lo Record with the above stated Registered
Numb and on the asis there° HEREBY GRANT A PERMI-
(Ad ess)
the to hold temporarily and . . t body.
(U r ker or pens Navin charge of corpse) (Ipt f rem° Ise dis f[stet how
Dated 19..44'/ (Signed) .i L.
mil ocal Registrar
This Permit is sufficient for the Removal (and Interment or Crema on) f a body o any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a T nsit Permit (VS No. 62) is required.
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