Casavant, Louis Form VS.al. 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 (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
Town
�Dist. No'�e..�7..County �'�r1�
4 �,�[Ity If city, give eet address)
Name of deceased { ��,(jr
-��yy�� Single, married, widowed, --77�,"�I � ��, �
Sex/. 72, Color.. or divorced (writeh the word)..V.Y,rLL(... . .. Date of ea__th✓✓.^�- Lr i 3 19�
Age . Years / ont oG..l Days Bir hplace..de� Z6 -2 3i / se
Cause of Death
Certificate was signed by fir.,?-j�,.rr,ru ... M.D.
Address 6-2-,
Place of Burial (or Remov I) /53'--Tr11:Y1 e
(If body is to be tempo it el in space later) 1 s hll
Cemetery.... .. .. ..- . .er'TlV L . ..Date of urial.. l d — 19 /�.
(If body is to be temperer' held. fill in apace later)
The Certificate of Bath containing the above stated particulars, 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 r gistration, have recorded it in my Local Record with the above stated Registered
Number and on the bas's the f I HE ANT A PERMIT
to 4''1,G6.A. t.. . L•,
e) Address)
the to hold temporarily and.... the body.
.r person having charge o pse) of[state how])
Dated I idertaker
/ - 19 (Sigt
Local Registrar
This Permit is sufficient for the Removal (and Interme or remation) of a body to any part of the State (subject to local
cemetery or other regulations).unless removal it by common ca er. in which case a Transit Permit (VS No. 62) is required.
5.
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