Barrows, Stephen roem va el. 11.23.33-0U,UDU(17.31l4)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
or This Permit can be signed only by the Local Registrar (Deputy or Subregistrrar) 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, LE IBLY W7TEN IN DURABLE BLACK INK.
Dist. No ` ,/
Town, ��A�" F el
« « »_Village._«»..»...»«».««»»....«»
or lty (If city, give street address)
Name of dec axed—_ .........«»«.».». «_... • »»»«»»«.«««.«».»
gle,marri ,widowed, _.*0
S .. «:....«. olor......««....»»...» divorced (w 'te the word) .»..»«««......«..«........ ..«.Date of h ...... » .../ »_.19 ..?
Age«.«...., .l ...Years....« 1', .......Month ...—Days mays Birthplace. _ .--
Cause of Death. « .«..«.. «««_�.»..«. ««..«:
-----. wasTsigned -
Address.........._......._._...— G� ^/e y » »»»»«.»... »»».. .».«»».»»..«»»»»».»..».««_» »..
Place of Burial (or Re oval) _ ».» » » » .... »... ---.
(If body is to be temp fill " ce at ,/
Cemetery«« ..»..».«. _... « ./ry''J »» _ Date of Burial.. «....._. »...« ....»..«.».19
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been pre ted to me, after careful examina-
tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW,
I have accepted the same for registration, have recorded it ' my Local Record with the above stated Registered Number,
and on the is thereof BY RMIT
w
to q -....Wer(41- - - - ,
ame (Address)
the« »... »»......».... «».».» _ ».. .»...._..... .» .».. id temporarily d_ the body.
(Tj 0 rtaker or person having charge of r e nter remo e, the of [ ]).
Dated./ ......d._.V 19»l0 (Signed) »..».. ««..»»» »» Local Registrar '
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.
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