Brown, Charles Form vs 61. 6-8-34-50,000 (17-7901) -,
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Dr-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..06 0/ Registered No. (3 6 7
-Town ,
County r.../J CLI-?.17--q.,,(4,7 . --\ +44g,•' - / 6 / cp. - ier- --1,..Jj•
0....y5 --ef Cit (If city,give street address)
Name of deceased '
/27 ZSingle,married,widowed, ,
Sex Color.' uf ..or divorced (write the
Age 0 Ye s '§,3 Months, Days IV thplace..
Cause of Death . ..
. . ..... ................... ,
Certificate was_V by A/ a, ,
Address .6-Z-6,7lar ... , M.D.
• ...
Place of Buipoi Removal).. It**
(If body is to be i.orafily held,fill in spice later)
Cemetery Date of Burial" LZ/64"11 t.Y 0 t419..t.T,
(If body is to be temporarily 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 ace,ted the same for re..istratio have recorded it in my Loca ecord with the above stated Registered Number, .
and .ft k basis the of I "BY T A PERMIT G' A A _
to • , 7.
,.•
.2&, — tie) ss) •
the to hold temporaril, .-id e body.
41;11: rt3lcer p x pers,p110 tre-cd4os.,1. °en&disp ate ow )
Dated .i e(---t-li• 49.s.., (Signed% 4A1- L.---
a - ,11:44,- Local Registrar
This Permit is sufficient for the Removal (and Interment or Creiation ' to ny part of the State (subject to local cemetery
T
or other regulations), unless removal is by common carrier, in which case a nsit Permit VS No. 62) is required.
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