Belanger, Carrie TOT/II I,. 6i. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Pr 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. /3 0
Dist. No 4-66/ County ''(-/e2,4'1-c.--L----_ Tftnr-. ge vreZ.f....i X2..e.44.70.7,
Name of eceased or City
7-rf:‹ . ,...77PL te--t__,
(If city, give street in ress)
,,, Syiiagle, married,.widJawed, . ...00,...Z
Sex../ Color bC/ (,r dwerreed (write the word) Date f 4.1-iri... %.-r-- 1950.
/1
Age 7.6 Yea 3 i 2.-
1?1 • .Days Birthplace
Cause of Death.........1.
Certificate was signed li - -.-:. M.D.
Address i — A- ig-S4.—A-1
Place of Burial (or Re .)1_.spaj
I(if body is to be temporarily , 1 -1 fe r) '
Cemetery Dat of Burial /ff- 19•gf
(If body is to be temporarily le it. lin in spa later)
The Certificat- of Death containing the above stated particulars. having be- presente to me, after careful exami-
nation, the.4fie appearing to he r;sip ET v CORREC.T,. AN?'TseAcToR. ,,, sor , loUIRED BY.LAW.
I have acce 47-41 the same f1 re,.:',tra . it" -- . ded it in . . ecord `; t. "ve stated Registered
Number, .j,, n th- •asis y - .f 4;34' 2 'ANT A PE 07'
/
the - ,,,,IF /Ft/
to hold temporarily • • . ,,Z14°- e body.
persiirg ebarg orpse) 4 04007.;;;„ o r .t h eee d of tate j)
pi' A! 19. (Signed) .
Local Registrar
This P. mit is sufficient for the emoval (and Interment or Cremation) of a body to any part of the State (sijfject to local
cemetery or other regulations), unles removal is by common carrier, in which case a Transit Permit (VS No. 62) ist1equired.
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