Bazinet, Robert Form VS.6L 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.Q
DEATH, LEGIBLY WRITTEN IN DURABLE LACK INK. Registered No. <i�3 d 4.3
Dist. Noses `��County t' e.. r� �4�-•�e.�•CJ� '"7:71e-441—""
r ty (If city ye street address.)
Name of deceased
-_ e ' ingle, married, widowed, �`
Sex of divorced (write the word). .. ...l.�e�`�/�("Date of D .
.e._
Age 1c 7 Years lonths.
... �. Days Birthplace. -N:a -,.rlv,,,�.4---,
Cause of Death
Certificate was signed by M .
Address
Place of Burial (or Removal) v. ,1--, ,.
(If body is to be:: ::: ; ::::
e )ate of Burial • cffbe a
The Certificate of Death containing the above stated particulars, having been presented to me, after careful exami
nation, the same appearing to be COMPLETE, CORRECT. AND SATISFACTORY AS REQUIRED BY LAWF
I have accepted the same for registration, ha recorded it in my Local ecord with the above stated egistere<
Number, and.-t<i e basis thereof I l-IFE ;F A ERMIT
- �
to ,� .
ame Las
the .. to hold temporarily a . the body
(L'nde. er or reou}lving charge of�e)
( r v or erw is ose state how])
Dated .. (" 19. (Signed) A. ••. 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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