Robillard, Louis Form vs.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
zr 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. Tom._ Registered No._.1t.._./_.`%_._
- r Village �.
Dist. Now 1"Coun �y�-e,,,,�„ or Ci .
1 (If cityive street address) r
t
Name of deceased..... .. .., ->_ _' $ <-a�-
„e i� -. ... - Veteran
Single, married, widowed, • (If veteran, give name of War) _
Sex `' Color t' or divorced (write the word)-(•- s..e Date of De th --) ( ,f 19-5 7
Age ..Years Months _...Days Birthplace., ' .rx o... '� r ; :..'
Cause of Death - --x- ,, „` -
Certificate was signed by.. M
ii
Address. — :. s -. /�_.- e , �''-4 �`
Place of Burial (or Removal),/...' .. _ s---- 4-
(If body 1s to be ttzmp rarity beld411 in ep ce later) -+ - _ ----
Cemetery _
,� y i
: ,-.4 (- ---'`�a., --r-�-e—4--Q- L) u: Date of Burial......? " t:.. 19 ��
(If body is to be temporarily held, l in space later)
The Certificate of Death ntaining 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 LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Numb, and en e.basis thereof �I fHERE 1:.,NNT A PERMIT Y
to c,-- e. .i'l..C..:�': ' _4'7 � i',
a am) ( dress) ...,
the y '» `- to hold tempos ly and .: i-x— 11,r the body.
(Undertaker orsperson bating charge of corpse) (Inter,remove,or of dia a of[state how))
Dated :2 ... � 19.... .,.. (Signed)..
Local Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) a body to any part of the State (subject to local
cemetery or other regulations),unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDOR IT OF S1I X'1UN OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CMIATIONS
ARE MADE
Date of f�7"Z��+^. ^ was ) e J' 19
(Interment or Cremation) `,1
(Name or CYmetern Crematorium, etc.)
d2
Section v ti- Lot No. frave No
(t,
(Signed) Qo..iJC /au-, r
(Person in charge)
r1
Address
Person in charge mast return this Permit to
the Registrar of his District within SEVEN (7) DAYS
from above date. j If no person is in charge, the
FUNERAL DIRECTOR or UNDERTAKER MUST SIGN ABOVE STATE-
MENT, write across the face of the Permit the words
"No person in charge," and FILE PERMIT WITHIN THREE
(3) DAYS with thei 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.