Beaupre, Frances Form vs.6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr 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, lilFGIBLY WRl IN DURABL ly BLACK INK.
�� Registered No.._...__ .4..fi
Town
Dist. Nil County Village 3
Or City (If city, give street address)
Name of dec,eased �'1�.IC� .
ngle, married; w10 idowed, / >P i
Se .�olorr divorced (write the wo1) GC/ Date of De. ., A/' 19..
1 �r
Age .�„{...� Yea � �--lonths.... ./ ys lrthpl�,Ce u��'/'f
Cause of Death ,/
Certificate was signed—by e --1 M.D.
Address �.
Place of Burl emov-
(i\fb�yistoSe e . '.� y 1 c er) �
411
Cemetery... .'16.. Date of Buri 19.
(It body Is to be t•mporarlly held, & space later)
The Certificate of Death c 'ning the above stated particulars, having been presented to rite, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have a ted the same f• re ' tr: .'.n, have recorded it in my Local Record 'th the above s d Reygi red
Number ' .� �� GR. A PERMIT h.. � �
to `,/ �'
the • : ,li / es )
to hold temporarily andr .the body.
(Un.• ,.er . ,• son g charge corpse) . e'/in a ova,or othery�se dis etat w]
Dated ' '' .) 19. �j (Signed) it/(/.r/ x/w�
/ Local Registrar
This Permit is sufficient for the emoval (and Interment or Cremation) of a body to any part of the State (s bject to local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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