Bergeron, Rachel Form vs 6L NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tr Thla 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 Town Registered No.__.._..5 O7
Village ..
Dist. No..... 6) -/Coun .74,e�..�.2a ' --- or City ,� �'z. . .&-�
'l.� ���+..�-C+r. ..... (If city, glee street address)
Name of deceased ... .. C-. .%.. .... /3yr��?.: `"L.---- Veteran ,--"L 4% '
,.--- J//J/Single, married, widowed,'1 Z (if veteran, give name of wv)
Sex / Color f i7 or divorced wnte the word).. . .. 4-` Date oKDeath ✓..°./. �.•.19../
Age........., .k Year Months _ :........Days Birthplace .,j.�t,��,,r ' L. i -Z
Cause of Death ;,.Err G6<-7 :`6' Yl: ? v .
Certificate was signed by... M.D.
Address -mow ---kr -
Place of Burial (or Removal) �. 'Y.7..1 z :c
(If body is to be to r rily ld II n ace later)Cemetery ����7c 19.•
� .... .,.. .... .: ' ��,,,-.�G ?�- ate of Burial
(If body is to be temporarily h, .fill in space later)
The Certificate of Dea 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
Numbkr;\and on the basis the HER GRANT A PERMIT
to �. ...G ... /C v - .:-.Z....... ... Via.. -e
f1
(s �)the L� ... -:� to hold temporarily and. ,!� . the body.
(Undertaker or person avingg��charge of corpse) (Inter, re ore,or otherwise dispose of[state bow))
Dated..., ./... .. .../.i...19Z/... (Signed) + - -
Local Registrar
This Permit is su cient for the Removal (and Interment or Cremation) of a to any pest of the State (subject to local
cemetery or other regulations), unless removal is by common carrier, in which case a T ansit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PHEIJISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of__ was ////7//f 19/I
(Interment or Cremation)
(Name of Ceme te y, Crematorium, etc.) :—.0
Section Lot No.712 Grave No.
(Signed)
(Person� in charge)
����-�
Address w GZ.02-
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 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 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.