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Bell, Howard Form VS 61. 6-8.34-30,000 (17-7901) NEW YORK STATE DEPARTMENT OF HEALTH OFFICIAL BURIAL (OR REMOVAL) PERMIT Or'This Permit can be signed only by the Local Registrar (Deputy or Subregistrar) of the Primary Region_District (Town, Village, or City) in which the death occurred after the FILING and acceptance of:a CORRECT AND COMPLETE CERTIFICATE OF DEATH,LE9IBj.0 ITTEN IN DURABLE BLACK INK. Dist.No 2...''bb// 'i .. egisterat N+fl. _. ; Town fz.s_e__c_‘__4_. County._ � A ..,.. .._ _......_ .. billd� . .....:... ..._ ... _... • (If city,give str L9'' ress) Name of deceased......_ WQ.:1,L17? X.......,.. ._..a ingle,married,wido ed, ` Se4seh..Color r divorced (write the word ... ......_............Date Death. Age . -Years......._._—...._ Months `• - .! ys Birthplac Certificate was signed by •a r s l ,. -, ja,.. „-.. - _ - - 71-t/ __ • - __.—_-- Place-af Burial or'Removal).--._.-......_ la 7 �-� - - (If body is to be to 'ly held,fill in spate later) Censetery _ _.. .. .Date of Burial.... . . , . .19` (If body is to be temporarily held,fill in spa ter) _ The Certificate of-Death cunt ' ing the above stated particulars, having been presented to , after careful examina- tion, the same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have pted the same for r -a ation,_have recorded it in my Local Record with the above stated Reestered Number, and the i» IfE A PFRNIIT ~ _- -,..--- ( me) Address) t to hold temporarily an _ _._..__.the _ 4,,- otpe arge a kite a , vise dispose• i -boV Dated 19.. (Signed). _.�.., ..�. 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