Davis, Sheridan Form VS 61. 1.23-35-25,000(17-5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
S$' 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.........� �� Registered No. ,1.7
County
Town
,.�y�ll/,----%/2--G' Village... T�?�--
or City (If city,give street address)
Name of deceased
Single,married,widowed, f /
Sex 1?f... Color r;z2 or divorced (write the word3 ......Date of Death ,7...,/`r2-- 7- 193 s�
Age...._....3.....7.........Years..r 7. .-..Months ' `_Kj Birthplace.. _.
Cause of'Death
Certificate was signed by ,22,_..,..� _._ .M.D.
Address.......-. Via.._.
Place of Burial (or Removal)._.. ...i�j- —(c � . �i�
(If body is to be temporarily held,fill in space later)
Cemetery_ .._ _ _Date of Burial / 19. 3.45--
(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 accepted the same for registration, have recorded it in my Local Record with the above stated Registered Number,
and on Vasic hereo I ��RANT A PERMIT ��%�
e (Address)
the __.... . .. _ ., to hold temporarily and the body.
(Undertak or person having charge of corps y% ove,or otherwise dispose of[itate how]).
.'3
Dated.... ._ ;1., 19... (Signed) a---1/(- .-...._.-
Local Registrar
This 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.
t 4
1"o. Ey O >, 0 v- ^w rn "c7 s. v^ 6. O yr bA.+ °w O rn p $..-. a , u v y w v, -U ,w,q t. 1_.};'n 4 '4 W
pawl., s0., o.0 a.) °a' O '•n v a0 o u.��O,O+2, O a.-0.tiy 0 .oo 0. Ny}0 41) . A o c3 .-O.+ O . O �1" p...•;y.''. egg.
Cr4 a � .� 6.0o.N. O ,. ra�w•-',p,0vida0iys_. c>din pno ov " u0 v v [ ca +,Ll03 O
O � 'D d a 0 y� �y 0,V 0•0 0 uaw 0 ..E1 .O:�y «.-..0 a t) v'n >' O C, v, s.0.) y G� � yy,'•
..4 p,� w vm0 ,dvvc,d.0v vwoa' v o nv o v y vas "� v vca d tt
„�,' O iti ,sU.' _'Dq•�rP%++"y ,a O�w-+ o-0p away w- ,y,•'-' •Qov :.,uU a - avazv. a.CY, a,
i.L, !'x7i 3 c0 v O .., A E a+ n s s. u a'^ a +
.. p.. v v w'0... i, a w C.. v > N� %
0 r r� .n �•.� L..0... N p,v p cd p w O s.w 3"•-� O O rn '++ s. t.y O c3 U O.+ v ,O�..p
,' w , ai .•+ bn cd u,..O ° 0p vcy O p y ',d .0 OO
d 3 w v .+ y v v • a O o a V U O ca v U.a O ,n �-.. � ~ "•C
ai '3'''.. .0
o iti o a v -[ �" v v v bo .c 0 to 'b C'. H v.r M
Q' \'\. .+[-• �'(A •C. -17; �. u" .O r^. a +�.ty>,vbbD - iiIIU
A. '. ti ..•.ti °O u s•p s.0 ,'a ° a'y4_, ...+ .'..'.dI. v >>pyp0,,,, _ •^N'r - uG;.? Li, od oo u � " ° u'- '"av
y) AZaA a) d aP >w C� C�d+O u1� x N v O• Q d 3 y0� P ai N i Ow N. N ��id�3 dp V C
ZH HA V-or/� 0� uAp0o6, O.ns.. o 1 a.0 m ai 1",„puE3 ° yo •a ° U .d0 ,04 wCI.-i
� ..�, yc a,M 0.1E-i-� v'° r., y LJ v.cw , 0mvv.zbcV v ,., O0 pA 4y v.nv o.' ''w a�o•; . p;.' 3
wW ..w': v C0� ti v a.�y a)...,•d v v �y 04.•�..0 •tiy5 ' s. 08. wai� �V ai a i'.+ E yo•- oo ca uE��W C
O "ad -o....0 a c� ca.•. cd u., O x O c"' a 0 4 > v bq u id.� y,., 0 O s, s. d V a .0-' cn V u ,.•�+
w W N w p y3, Cd cd y U v,� v L...+ .+.,J cd .+ O > �., d of p, v v vu m a b11.0 «f v ,a d 1-I W.;
0� v4 ai 0g F+'.80 v >, �v... b �� OyU unj 8OF .0tt, >,> a)y uamid.- ems°. •"O•�w a'�.CW�
(/�a�i eg '1,,, Q O,9xF,i.... b ua'',., cd m-0 cc1d U ' rn u3 w'b s•'^Q�a+ � u'.o.CO �.. �. .� 3u Va y ,7-, C
O >>.� s. v CI.0 J O �,C COU
W H .q m E+ H'D O cc. 0 a u p 0 0:4 0 .I.) '.v).0 0 v'-' .•..,..0 ,v, ..,... sy y,, .. c.,w'b O bp,.q rn eD,�.�Gp
v.. b cd v y. >.. C
•
g, 'G 00 u w 11.o s, O 0 O.'�... v.+ cd .. ',0., s, O y .... 0 U Q Y, O •.G rn..' o Q W a
0 4, s. .0 .. Ora v v O id... s. .0 u.,, v ca w a) C .-. vc F >,• W F
alZ mf� gvz aitl, ° ° a� � � id 3N� ^w c7 .c v ` a �a o ° � oy oa' � v �d hC+
aH q ►r '' -0 ea'c30 u.C24. ? a~) y v � id � su,--' a° 3. Vuu.0 '� ~ av � � m'yiaO � �p[�0a
�a e,.0,w'�z w4.adycdy-Om V cdUv. b > �. O.a o•:" s., O .,N.'•UYid.' bu0....= p ," opca 0S,' ,fin V s. u7
O`�(,fj w U.�. .E-. ib O N ,1 u.6) U . -' cd-.0.,.., ya 0._- ti u ,5-u 2, v w.+ .0,+. O u - ct - . g... 3 rd ° £,. coal
V o _ �;.. O O F.y E p P O m ". = °.'.... cd F ,,.. .x p C N v u 0....b .� '" td pi- :n v u -�v...,-i� W 00
zHZ .. ,, q o ,,a >1i uv c.. F•1-0.. Ot, m o vcd cd.. s Z, 11-0 cd ow uu pC >,ic, ,.•5 aj bt. .- CCa�ya
i u ; i' �' V ei a... s, as a) cd u.1 U ..,,� p Q' u y,.4 p .^ ai as.-. a ,n 0 cg..-.... L
v O y Ca -0 U O.+ .r B. in ... > ,,•0 ,,_, «S a a A ,id d)w ,•b u w N ca s, y, a) W a
W Ey'd O .++ > u a ., y q.y C e) >,`*+ .. �, O id O.ti s.•a 'O., ,�`" G'.c >r O.'O+ E"'� C
8 .rca 1'% > Eti v 1b''5 o v v o v ti 0 A ° v "°
.-r c E a ,-•c y W Q � �,n v � r. ..., � cd � A u C...,,, ° ^. �W
H w ,. u N o'id a °•; v u 2,u V b 0... .o op > a., ,a'C s, v- v ,n O v u H a
y o, ;; pr 8 .0 o o w 0 w 0 O Q
t U o..,�,, O ,.cy U U � v O b cd .-. ca u ..G r�
1.14 •#.�" wo 03C4 p E.1 y, O 00.y N.�"a > rdacy.d Cpiu•, "'.p. `' y vO O4..' ca aeOa; mto0Ou.0 V in.� ad' ..G,�.....0a"H 'C
.. "' O A O v'. a'-o.c O " •^ U ao JtI
� ^ .-, p y m . Oemu v � CYiy t."av, ° yVo...-0ca > I- q m 0-•-• 0 E"djig
mhIIHi
O } v b4 w Z. o W o•.. ca m y , U^ A0N 0w" a•cyvo0bn .- 40- '-' ,I, 0`or~ ZL'Wtioca s. u y +., d st m ,.., ° s. � > U v � � .ti W'abi Oi." aGm,b.+ ►d id y.. gi.+ UJ O O O 0 ct-ow c'* C cdNOa V.. M UOcav " �.�.0y< 0
> s.y v• w 0 ai O u.t '� )..c'. ,.O cd'v, fd v a u C• ) bA Ois s. a,'
I�r^i�i rr •..... � w E� >+ .� ,� bn� a o 0 ; s~ p.� a* ° � o >,w ,n v .,., o � ,, � a� d
z a >F0 Vw.� id apiys. s. cu.. 'O = O ° a w".2., ° .... , O';r Uc3m... ar° •,y ,-, in V vOv Q'0 -' cq
�� �'O� �S'i � N•a su, vO.C� uwv � Up'O. ccd.O+� N mN °'C wO � G'*'' c°a q.,.. am � � a�(%)�"uVi � Qc��'"OU �'fl �4bZOO Mk
w.; i. N E"c s. m, .0 cd O c1•-'.-. >,£, t-.., s. w 4
W .� V]ti E1ac0a, >,A' w.0u.+i,E5.44c.G.u) v"b ,nc•.'lacca'� uia•U-• 6, a•.7 ° 0cda4� acwv, > cu. aiOid0� O.uw0dA
U0 W ~ u.., p m u.., c,. ,n ,,,, zou b.r V u OQs, v.p .44 0y Cq0 •O.O V
C4 '� •.O.",.q A W CL� p 0--' a o n o [y a c7.= 0� A 4-,- u 41)'-'4 I a ,,-, •^ a "ho•-. z 0.•C• r cCal.cl.,4 0--,•• �•v o' ,. P11.-""-, i.
O C4: O V.. .+ v v•a'i+ 0py s va) q '..0 .4.0w V O ° ' >,C1b pO >.9Owvuv 004 W.�`..
C.1 d
m0i�, 0 : TN .. O / s+I:H.II
>? qm�4..-i ~ -t¢¢.,.•. My� ° E. > °�.4 ,n os`I .L -di]1! ° !i!P1ii- I
.cd ,Q. v �b G• v.� 0 0 oO£Azo;A t0'o `' 0oo.° •., >.� °y. cmun3.� in
p.atj5.5 � b�oa.5 °p +- g �,
A Cr) W h.! dw .-vO s.40p.C"0 ,u.'C0vOV c ac.) o ova)4aad ,.Cc. boap0 >,>~ •�v'b id 0V 0•> v 44+ + V
A �-.0 "-.0 ao 5'•04+ ,n o 5w 3 3 0 w 3 Ca, aw as U.� orate,0b.� 0 0 01 i;.ow o cd.0 o wx =b w o�'big O.C".a