Beaudin, Peter Form VS.61.. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'' 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. 0 O . ._._
Dist. No. Tam
,,�Gq...County..... .. �� yf
"" �•.age.r;(.,5.7.. 2ug`�fi ^41 ..��ie,et 4ra-' 20
. f,, or City i (If city,give street address) r
Name of deceased ��
v�C.. .
Single, married, widowed, �� � �
Sex... . .Colo ...or divorced (write the word) GZ Date of Death.. f4‘ /4- 19..lt.,7
Age 7s Years 6 Months.... .? Days Birthplace.,.�� ..Gr � % a4�.1r
. . ..... .
Cause of Death 771
Certificate was signed by �f„ M.D.
Address /... .. ..
Place of Burial (or Removal). .. r...2?.61 #t'424,....i._ i _ ,
(If body is to b mp r rill 1d,1in in space ater) it
Cemetery... Date of Burial /2/4194.3
(If body is to be tempor ily held, fill in space later)
The Certificate of Death containing the above state 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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number,ern on the bakip ther f, I �EBY�GRANT A PER14� I;/� That./ !/
ress)
the to hold temporarily
aan�y�" . .. the body.
( rta er ) ///(In I)
Dated... . . . . .... .. 19.Vvira (Signed) ../. ... ..
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
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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