Langlais, Martha fo1•rn I,s.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 (Towi
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE 0
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. R gistered No. 3' Z-
Dist. NoS'O f County -M,,.,, e �
Villag Tnwn
-,. r Clt (If cite, ive s t address)
• Narne of deceased4
�� ) Single, married, widowed,
Sex. G CololN/ or divorced (write the wordl-32*-� -'-:' Date of Deat i/ 19. e
Age Y ars L Months Days Birthpl;cc.
Cause of Death... ....
•
Certificate was signed b .. .... .. . .... `?"Pt.t l .E
Aress l ���
Place of ttri r Rc:mo 11
(if body is to be e o ly he X lie late
Cemetery... . . .. . . ... .... �l Date of urial /3 10
(If body is to a to Iporarily held. fi In space later)
The Certificate of Death containing the above stated particulars. having been presented to me, after careful exami
nation, the same appearin, to be :i `f , CO CT, AND SATISFACTORY AS REQG1RED BY LAt�!
I have acce�p d the same f'ar „ - ec:r. �d it in my Lo with the a s d Registere4
Number,,j, . . -r: , . a .- j; ;. • T A PERMI
to t
the 7e to hold temporarily and. sody
(ti ke.�r�orr errs rrse) u having charg or otherwi to bo
Dated '"' /J .19 .y ..� (Signed 1 ,,... -- -_______±..."
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to Inca
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