Robillard, Florence NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gar This Permit can be signed only by the Local Registrar (Deputy or subregistrar)of the Primary Registration District (Town,
Vilrage, 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, Village Registered No.
Dist. No. SLd\ County �?.S}„ �. or City Q . .r `C-
(If city, give street address)
Name of deceased N AC..9-- C � Si.SZ�... . Veteran .......
(If veteran, give name of War)
Single, married, widowed,
Sex ,..$)n{h�, ,.9,,, or divorced (write the word) ..AQ.1 1.9-c)). Date of Death ... ..19 —1 k.
Age "--r1 . ...Years Months Days Birthplace N-�-v
Cause of DeathsgneU-CWild by,.9,..0 .. '4 ,,,D% c` . ...... .. . .w... .�iios.9, !- r...._..
Certificate was signed by .... ... C3--,--1ZNN. M.D.
Address ..3/. . .. Cs- ,rR.....t..�ac.1' S.�.,P-` .
Place of Burial (or Removal)fii " ,.. c?
(If body is to bet por it he d, fi 1 in spa a later
Cemetery -e-1---z. Date of Burial ,.V ' 2- 19'? J
arily h(If body is to he tempor Id, fill in space later)
The CERTIFICATE OF DEATH containing the above stated particulars,having been presented to me, after careful examination, the
same Appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
tion, have recorded it in my Local Record with the above stated Registered Number, and on the basis thereof I HEREBY GRANT A
P �Edtfi
to .... .... ..... rFame^ ) J �C..0�j'i.�1.Q... , A` ress .?1..c �.. ...�r
the L,).J'A.. to hold temporaril and 1--7---. the body
(Undertaker or person having charge of.orpse) (Inter, ove, or otherwise dispose of (state how))
Dated D M 19 r (Signed) �4 ,,,ei
Local tray
This Permit is sufficient for the Removal (and Interment or Cremation)of a ody 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.
Foust VS. 61. (REV. 6/63) (A2-248)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of 7& was o2 / 19Z
(Interment or Cremation
/24
(Name o Cemetery, Crematorium, etc.
Section S J L Lot No. / Grave No.I
(Signed)
(Person in Charge)
Address 35 G J�C`) 1 Xv 4 x g4 /V, •
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 UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "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 required, under
penalty, to report violations thereof.