Cloutier, Rose Form VS.a. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) :PERMIT
ttr This Permit tan 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 Town �j� Registered No._.,,,.. :....._
Dist. No -s‘A.l....County. Village .,G Q�,�'(
...��,��xt:lrLrC... or City .mil
4-21,-- a.g e,,....
'• t (If city, give street address)
Name of deceased ��Q .. ..... .. Veteran
bv-
Single, married, widowed, (If veteran, give name of SiW )
Sex "Ni, Color or divorced (write the word).. .kr.—--4, Date of Death f\i. ....a? 19Age i,L. Y .� Mon Days Bi place Q=� .r.17.
Cause of Death-...
Certificate was signed by j WLr�:k,.r M.D.
Address �3j m
Place of Burial (or Removal) % � wt,:�2 , `
(If body is to be temporarily he d pa later) _�� _
Cemetery ... . Date of Burial C ..tea 19 S /
(If body is to be to orarily held, in space later)
Thq 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, aniP on basis thereof-I,HEREBY A PERMIT R �,
to .4.6,.�� ..zr..a.�,..r - �.>7- c.) 7 - -
the (Address)
,...;;, .,4t.t— to hold temp and.. - r- the body.
(Undertaker or person having charge of corpse) (Inter,,rem e r ,dfsnose of[state how])
Dated 6-1/ , ., 19. .77 (Signed t-- ...----
, 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. ,
ENDORS MEW OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
t
el-----''Date of ,.t_-C l,-r.r.-. _-, f- rK , — ' 0 i9 v
(Interment or Cse t1 )
(Name o Cemetery, Crematorium, ete.) ,J
f
� l
Section Lot Na. (� Grave No.
ii
(Signed) Vet) A,s oizat.....e._
(Fe ao n charge)
% X G .` ' --�-x,__„
Andress / �'`C C
7..
Person in charge mist 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 wards
"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.