Maille, Emmanuel Form VS.IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sr 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. -TIw— Re ' tared No._... ,.
,...,____ei.€1_0_54...,
Dist. No.`.?.ra.Q Coua --,`-�� Villageor City cc.--e4,. .. 2,:=2: 2°,
(If city, e street address)
Name of deceased . ... . ..... . . . . -�%�� .... Veteran
Single, married, w1� (If veteran, rive n/ a of War) _
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S . .. . Color /A) or divorced (write the word)...... .. ate off; j ;-.. . :'.....7 196,1
l»»...D s _place .. /���� / �.
Age Years Months. _
Cause of Death .. /
Certificate was signed by. . ' M.D.
Address ....
Place of Burial (or Removal) � ��,-;e r 7-
(If body I.to be topp'gqyyra h All space later) _---
Cemetery -c f . ... ..t_.. Date of urial '3 7/ — 19.���
(If body is to be temporarily d,fill In space later)
Thn Certificate of Den 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 LAW,
I have accepted the same for registration have recorded it in my Local Record ith the above stated Registered
Nu and basis thereof 21!E1311T A PERMIT
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to .. > C_ -''.
the ".�/ .. .. to hold temporarily and.... ... the bdy.
(Undertaker or pe n having charge of rpm) (Inter,reygore,er othererkse disease of[state bow))
(Signed - ;-::x w.e.-. ., ::: a -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 local
cemetery or other regulations),unless removal is by common carrier,in which case a Transit Permit (VS No. 62) is required.
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