Poutre, Laura •
Form vs. al. 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. ".e
Teva -
Dist. Not$/ County tge .
It / (If cit.', str
eetgive address)
Name of deceased y-
�� Single, married, widowed, •
Sex... ... Color / • or divorced (write the word ...... . .. .Date of D h.. . ..G /f/c=f/ 19.
Age ...Ye rs .c .Months �e Days Birthplace ‘ `7, •
Cause of Death.... 4.. " z :.:. .. .. .. .
Certificate was signed by • .., ....M.D.
p
Address I .i'/i ,
? i
Place of Bu;ial 'emoval) .. . .. wf v 7
n v .... �
(If body is to be �.• ray held,fill in space later)
Cemetery.. Date of Burial or ��. ../ `;'? 19
7.2
(If body is to temporarily held,fill 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 hay- ac,-pted th- same} for registr: ion, have recorded it in my Local cord with the above stated Registered
Num. _. and on t e4��`'�/ thereof // ERE:Y T A PERMIT = ��
to....re ,!.. ! ��„ %�� G�
the �� / /' : :: � �s J...�, •
•• ! .-�'. to hold tempora ' • and t ody.
`i_'e ak• or pers.n .acing arge of or se) re o e,oy1}�er o [eta a ho )
Dated. , ./' ; ....a. 19....�„ (Signed) 1 .,..p
Local Registrar
This Permit is sufficient for the Removal (and Interment or Crema o a bo to anypart of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case ransit Permit (VS No. 62) is required.
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