Coutu, Agnes Yorm vs.si. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or We Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE CERTIFICATE OF
DEATK LEGIBLY WRITTEN IN DURABLE BLACK INK. Town .1!$F4
Registered No._...._..__.....__......._
Dist. No.... ':102...County.. -..B'enss:................... City Troy, Pd.Y.
or City
(It elty,give street address)
Name of deceased Agnes Coutu Veteran
F ;iv Single, married, widowed, Cu veteran, give name of War)
Sex . Color or divorced (write the word) Date of Death Feb. 19 19 59
Age g7 Years Months ............Days Birthplace. to a da.
Cause of Death A'Y.Qa .xri ia.1.,..fa i.l.ure
Certificate was signed:by M.D.
sj ri.tca M.D.
Address. r 8b `a frsb...Au-..
Place of Burial (or Removal) ( .ens i'a.1.1s.,...N..:1..
(If body Is to be temporarily bee,ra in space later)
Cemetery -- a 7.1..... . haiase...Crtrl. Date of Burial Feb. 21 19...5.9
(If body is to be temporarily held,(iI In space later)
Thu 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 LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
Number, and on the basis thereof I HEREBY GRANT A PERMIT
to Brotm a.nd iihl r — V r/Lin...L,.....I' hler ..5..i1....kKsL1aaln...giy.•ydo is.>ri on,
UndAker Inter. (Address) 1 Y,
the to hold tempos� ly and the body.
(Undertaker or person having charts of corpse) 1✓ Inter, e,ogt>aerriM rose¢f state:Ini i
Dated Feb, 19 19.59... (Signed).,.-:.1��L','7 ,- ( c/(a.% C&I L 'fr ,L_// �f/
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 remora/Is by common carrier,in which case a Transit Permit (VS No. 62) is required.
'ENDORSEMENT OF SEXTON OR PERSON N CHARGE OF
PREMISES ON WHICH INTERMITS OR CREMATIONS
ARE MADE
Date ofql" 'ti was 19
ateterg„..n...c.s.r.
r
(Interment or Cremation)
(Y K.
(Name of Came y, Cremator um, $tc.)
Section Lot No. Grave No.
ciA.
(Si wed) ame4,0 ,,,o.,.):a+nt� �"-
,4.... .....
Address S 5 -(4 § - '
•-•ee./t,<,--
ls
Person in charge oust return th Perot/ •
the Registrar of his District within (7) DAY
from above date. If no person is in arge, the
FUNERAL DIRECTOR or UNDERTAKER MUST S GN ABOVE STATE-
MENT, write across the face of the Pe it the words
"No person in charge," and FILE PERMI 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.