Coutu, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
rie 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, Village Registered No.
Dist. No. 1953 County ate-ene or City cc -. -
(If city, give street address)
Name of deceased R'agrozad....2... Co.tatL Veteran
(If veteran, give name of War)
Single, married, widowed,
Sex aCa-e- or divorced (write the word) m 'Led Date of Death 70-5 19 69...
Age 73 Years .Months Days Birthplace
new Yoitk.
Cause of Death Rati. :4,11...a...Ga/zonailri...i aia...attack. ,
Certificate was signed by RQ.44114 T. Cheung M.D.
Address lltee:ZfJoIi..LGX -...tiQ4,r? ..Qt Q‘....wG2et2•e CQW-tt ,.Ca. k l.U-, new dQizk.•
Place of Burial (or Removal) .t, .en- 7CLL L- ,, new Wohk.
(If body is to he temporarily held, fill in space later)
Cemetery St... fliphandauz Cetne<te ty, Date of Burial 1.0— 8 19.69
(If body is to he temporarily held, 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
PERMIT
to Iii. pacL9h. Tune/ca. Home 257 II:Q-t•n S-tiee-t,Cca4k.i.4.Lx flew , a4
(Name) (Address)
the unde4-take4 to hold temporarily and 44-iete, the body
(Undertaker or person having charge of corpse) Afar, remove, or oth wise d spbse of (stgte how))
Dated 10-5 19 .69 (Signed) .�. ►/i.:.. .• /L<
Local egistrar
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.
FORM Vs• 61. (REV. 6/63) 13A2-323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
Date of was &ter O 19 (p
(Interment or Cremation)
(Name of metery, Crematorium, etc.)
Section Lot No. C. Grave No. `s
(Signed)
(Person in Charge)
Address ,1
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.