Beaudnault, Albina Form VS.!IL NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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 CERTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Town Registered No._ '
Vine
ty...Dist. No.... ..t:.t..r:Coun .�% ..a.&x or City
f` (If city, g ve street address)
Name of deceased �'"�- , Veteran
f4/ Single, married, widowed, / (if veter . si a Tim of war)
Sex....L Color / or divorced (wnte the word)... .fk/u Date of ath ` .S 9 ...5,
Age ; .,S Yeas.'. Moths Days Birthplace.. � /
Y. .`,� -4-�° - `e'`^
Cause of Death.....,o� 1.)'u'4--e' z- -�-, z.-`-"`,,r, ��
Certificate was signed by 1.D- --'''-�'Y / e `-"- M.D.
Address .,.w .f:L fre
... Z�--- 7'
Place of Burial (or emoval) ������jjjjjj /...olek/ 7.....9 -� -2—t-t� mac- --)-7 P
(If body is to be tempo 2 beAn i sp latex') r
Cemetery ����//¢'+J� "?A- „o CQtti! Date of Burial 19'
(If body is to be temporarily held, a in space later)
The 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 SATISFAC!'ORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it in my Local Record with the above stated Registered
o \ / e the bee'/ pt_n� I HEREBY G.. A PERMIT ? ,Z7D'Il
)1,7
t
� � ` (� ),/
the .' e, (Address)._ to hold temporarily and., the body.
(IInde dr r pe ha ng charge of corpse) (Inter,remove,or otherwise dispose of [state howl)
Dated , 19i....:.. (Signed) Local Registrar
This Permit is sufficient for the Removal (and Interment oe 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.
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE OF
PREMISES ON WHICH INTERMENTS OR CREMATIONS
ARE MADE
Date of was 61L. A 19 413
(Interment or Cremat )
(Name o Cemetery, Crematorium, etc.)
Section Lot No. 2A5 Grave No.
(Signed)
'V Ili �� 44.
(Perso in charge)
Address 1 ' C' 14,1( (o O O
Person in charge must return this Pe it to
the Registrar of his District within SEVEN (7) DAYS
fran 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 ON'ri,NSE.
The law will be enforced. Local Registrars are re-
quired, under penalty, to report violations thereof.