Bazinet, Marie Form VS. 61. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
for 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 CERTIF C jT OF
DEATH, LEGIBLY WRITTEN IN DURAB BLACK INK. �✓ R isteredtere No. a. C'7
Dist. NoS 0/ County `� 2 .. li'i�1 O -44 -_
�a�. /..1
Or ty (If cite. gip,street ladress,
Name of d ceased
/,, Single, married, widowed, .
Sex Color..LC/ r divorced (write the word). Date of Dc th...... .... 6 19..ri
Age 97 Years .Month / Des irthplace..
Cause of Death (�
Certificate was signed by.... \I D.
Address __; .
Place of Burial (or ! moval) .. . .. ....... . . /
(It body Is to be tempo .,, I : d, cre la
Cemetery • a Date of urial.. .... .. . .. ... ......./e9 194
mo
(It body Is to be tempor ily held, till in ace later)
The Certificate of Death cont ning the above stated particulars, having been presented to me, after careful exami-
nation, the.-same appearing to be COMP TE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW.
I have accepted h 'same for r st ti e r it in my Local Reco with the abov Registered
Number, and o ,<e basi H A A PERMIT
to
me ess)
the ... to hold temporarily the dy.
(Underta;11 or .e :o bg charg P cog ) t r, 0 other vise oae fate howl
Dated 19 (Signed)
Local Registrar
This Permi is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is require .
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