Akins, Clifford NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL , BURIAL (OR .REMOVAL) P RM
sir This Permit can be signed only by the Local Registrar (Deputy or Stebsstrar) of the Niamey Registration District (Town,
Village, or City) in which the-dealt occurred after the FILING and acceptance of a CORRECTANDCOMt' E '$•CBRTiFICATh OF
DEATH,LEGIBLY WRITTEN IN DURABLE BLACK
INK.
Dist.No.. 4...L6 h ate d No.
gyt Vi . _ _.. _
(If city,give street a ess)
fame of decease .. a _...... _. x.... ..,......_.. :. .._. .........
married,w�vrv6Pd, � ....._ ._._._..... .» ... _..._.. _........�
5ex,.����Color`�"` ....or divorced {write the word} . ....., ....Date of pea . ...._.._..19,
Months Days R ce..4 `4
.. .� r ,
Cause of Den _ - ..._ ....._
z; ..
Certificate was sign- b M..._.._ . __... .. _ .. _ lz' _.._......_.._............. _... M.D.
Address_ •_ ..., ..t. _ _
Place of Burial (or Removal) _ f /
(Yawl istob _ bli' elates)Z,,e,, /4 A.
Cemetery _ ,,.:.._r. . Date of Burial_ z to 19. ..
(Li body is to-be temporarily held,fill is apace later)
-fie Certificate of Death containing the above stated particulars, having been presented to me, after careful eaamina-
tion, the' same appear'ing_to -lie COMFI.RTE," 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 Nam, -
and on tie I HEREBY:GIANT A i _4d:
t of
-. (Addr )
!
ess
h {Name} —.........—.............--to hold to nporaril and
.. the body.:
sidelight:iv or having charge cOr,ese) (Inter,r ,or otherwise dispose of[state how]).
Date ! .19 0 (Signed)
Local Registrar
This Permit a sufficlent for tie Removal (and Interment or Cremation) of a body to any part of the State (subject to local cemetery
=or other reg ),swku ovef is by commas carrier,in which case a Transit Permit (VS No. 62) is required. _
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