Primeau, Albert Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
a2r This Permit can be signed only by the Lo-al 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 CERTIFICATEN OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Registered No GQ�
Thwri
Dist. Nos 651 County "' e. .."�"e4C f
or City (If city,give street a ress)
Name of deceased ,.. .. 1
Se)2' '�J�� /// Single, mar d, widowed, •
-474.Colorg. or divorced (write the word). Date of eat /1/ 19 5i3
Age • 7 Year ... ... Months 7, Day Birth lace. 4'--" -
.... .s
C:�.use of Death...... .. ,.
Certificate was signed by.. ... .1.6!... M.D.
Address .... ..... ...y� ... .. ....
Place of Bu;ial (or Removal) f
(If body is to be temporar: -Id, sp later) 3
Cemetery.. .... Date of Burial. 7,,V 19
(if body is to be temporarily held,fill n space later)
The Certificate of Death containing the above stated particulars, having been p sented to me, after careful exami-
nation, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted a s. fo regist at n, have recorded it in my Local Record with the above stated Registered
Number, a il�sis f BY GRANT A PERMIT
to yt
Address)
the to hold temporarily an the body.
(U rtaker or person h ving charge o corpse) (I em e,o of ise ) se f wl)
Dated. .... ,f 19 .3 (Signed)...
Local Registrar
This ermit 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) s required.
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