La Freniere, Carrie 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
''r This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Tow
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICAT F
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.
� Registered, / No.
Town 741..tee �tv �.�`.�tS�f,[..ri��
Dist. No, �..P../..Countya,/ d�.c�rs.� Village
Or City (If city. give street address)
O ,
Name of deceased
� �..S._ingle, married, widow d,
..,Se r lor ��L_ C, r divorced (write the word),X ate of eath.. ... .. 19.‹..;
Age ,/ Years VI the ; ays Birthpla
Cause of Death•
Certificate was signed b ,.. .. .. ... .
-�-.. .- .) M.D.
Address ... ...
Place of Burial (or Removal) ... /e.,,,,,,_„.44.... .. I„
(If body is to be ora lv he d, 1 I in space later)
Cemetery... 1' Date of Burial . .., 19("As
(If body is to be temporarily held. till in space later)
The Certificate of Death containing the above stated particu ars, having been presented to me, after careful exami-
nation, the same appearing to he 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 don the b is th eof I,H R BY GRANT A PERMIT
the ) to hold temporari (I body.
(Un r e+'rerann tli.9 rgo nP e
Dated 19.'`. (Signed)
Local egi tray
This Permit i sufficient for the Removal (and Interment or Cremation) of a body to any part of the State s ject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is equired.
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