Branch, Mary NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Pr-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.
Dist. No.... ».... Car :a c p r( R No«..... .«.»......
County««« _ A... »».-..«.«.....»«»..._««..««».«V lla «»««« ,
---4�� 1�� O -�ty » « (If city, give street address)
Name of eased «.. « _• « « ..«« ». » ... » ...
Si e,married,widowed,
S Color...«..,, .«_or divorced (write the word »«« «» ».«« ««Date of ath ._.19
Age» ........ .-....Years.................:..... Months— . ays •Birthplace .. »
h« „ . «.«.. .»...«.»..««.. «..«...« «_.« ».... w
Cause of Deat
Address-- ««««..««« »««««.».». , .,64i _.«..«« » ««.._«...».....»...
Place of :urial •r e oval)...._.......
(If body is r. •' ter•.ran d, fill in spac ter) ««.«.«« '! ««« '�.
Cemetery Z.,.., .. 1171G,«»««« «_««« « ..... «.».... « Date of Buridl ,.; - .. » « 19«
(If body is to .e mporarily held, fill in space later) «.«
The Certificate of Death containing the above stated particulars, having been presented 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 in my Local Record with the above stated Registered Number,
and on the bate' thereoftyRE G T A PERM T
(Name) ««. Ad r ��
the..._..«... ..to hold temporarily and.'-'''..-*444-456:1,4 the body.
«.. .. ..««.... «_.«..«.. ..«..«..«.. ....««...« x�
(Tin er person ing charge of corps_ (Inter, re e, oth se dispose of [state ho ).
Dated ». 19«. ,� (Signed)..«. ..,
Registrar
This Permit is sufficient for the Removal (and Interment or Cremation) of a body to y part of the State (subjire 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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