Bazinet, Joseph Form V8.aL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
fir This Permit can be signed ealy by the Local Registrar (Deputy or subresistrar) 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 SLACK INK
Town Registered No.__.._...__.V.A
Village // / �, l,/
Dist. No `41�i.�...County....... :}:. 2:t... or City ,1� �`-y �� k
L /J � Td (If city, give street address)
Name of deceased .e.'��Q. :I L.._, Veteran �'-
Sing e, married, widowed;)�""`14 (If veteran. give name of War)
Sex Color... or divorced (write the word) ) �i'�-ss�.Date of ..' ..^\.may 7 19..SI
% z
Age :;.. Yeao Months Days Birthplace. ,/ :,;: .t.e ... 1 ,•
Cause of Death .,ti..... .. . ..e•..,.
Certificate was signed by ... ..... ,����a^�- M.D.
Address ..1 � ;
Place of Burial (or Removal) 1 j
(If body Is to be temporarilyibeld,fll ace later) ) 1 J '
Cemetery >/....:, /a... 2.� ... ,(..c.,a.. Date o Burial
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, havingg been presented-to me, after careful exami-
nation, the same appearing to be 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,Ztnd on the basis th °f I-HEREBY GRANT A PERMIT
to ..14 it , .4 e...:i '`.-.1�e 'G,
me) , ^ (Address)
the to hold temp ri:y and.... .tea,,.., the body.
(Rode r or non ha rig charge of corpse) (Inter, mos o;herwiss snow of [stab bow])
Dated � 19..:5..,Fj'" (Signed .........../.�t-G.:-k:K-�-s..�.,1.
Local Registrar
This Pe is sti cient for the Removal (and Interment or Cremation) of a body to any part of tho 'fate (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 82) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of r_ was 'lti L i % 19
(Interment or Cremation)
(Name dt Cemetery, Crematorium, etc.)
Section Lot No. Grave No.
4 ^v V 1�
•
(Signed) �``-'�
(Person in charge)
Address U' ( / ti 1C 6-ri
Person in charge must return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the cords
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with the Registrar of District in which
cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits
are liable to a penalty of NOT LESS THAN FIVE DOLLARS
NOR MORE THAN FIFTY DOLLARS FOR THE FIRST OFFENSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.