Robillard, George Form vs.el. NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
gir 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 CERTIFICATTE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK.. Town Registered No._._-._. /'
Dist. I�ToStr'cl County...l�...��.�:�'J'`-'�-T`-- or city ... ge..yz..w.... 7 �,
Q /� (If city, ve street address)
Vame of deceased 4// 'n-�^—� e_ U �< , �' Veteran(�t er.n. give name of War)
Sex /7�j Single, married, widowed, �"`" /
Color or divorced (wnte the word)`-r Date of D a - l •19••6. .---
Age. .... YQare ..., Months / Da ? Birthplace- V
:ause of Death..... . . - ....1,f:"....... -. -�- '
:ertificate was signs by . ..a..-k— M.D.
Address . .
Place of Burial (or Removal) � ..�,.a. -'.�:```..yyy
(If body is to be to po arily he d, ll in sip eater)
L ater) 9/ /i
Cemetery...... L Date Burial ``/ ,l V 19.4 ..?-�'�
(If body is to be temporarily held,11 in space later)
Phu Certificate of Death F ntaining the above stated particulars, having been presented to me, after careful exami-
iation, 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 Reco. d with the above stated Registered
Number on the basis thereof I HEREBY/RANT A PERMIT e
o. 4.� /'/`:',.-A":..?:tr.�'r rt:x::�. ... .r , J G.
a...) 5F ( dress)
he — : ... ....... .: „ to hold temporarily and the ody.
(Und taker or person having charge of corpse) (Inter,remov ,or otherriee jdier)ose of[state how))
Dated /7 i9. Z_ (Signed) 5..4...1' � .
.. s1 Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to any pert of the State (subject to local
:emetery or other regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE ®F
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of 1.t-
��jL 2,.._, „I-was 1.,//_�.'L / T 19 6
(Interment or Creaxti 4)
ea.eIS Cemetery, Crematorium, etc.)
'ow— _
Section if Lot No. 3 Grave No.
(Signed) id'p
r charge
Paf 2ediat,
Address t ( c c
Person in charge must retatif 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-
RENT, 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.