Ellisore, Erra roan va ea. i i.i3.33.sn,ovs(i7.31l4)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
Illr 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 `5f _ _ Re No. ._.._...-._..-
- Town, '.41...41;"County.......... .....-. .._ _ Villa e _ address)
.� », ... ..
(If city, give street addr
Nameof deceased. _._. ....... _ ...._... ... w - _...._........__...
gle,marrie widowed,.
Sex_�........Color -._-..-. divorced (write the word) ate of Death _ .19._ J
Age_ ...YearN. _... Months G Days Birthplace..�1..p
../,f a. ._.., • -
Cause of Death. „ _ _...-..- . W.- .-_ ..____ ._ — . .._ _ .•
Certificate was signed by.. ...... .. .... ...... _..... :.. _._. __ .... .._ _ ...._.....—..._.._M. D.
Address...... .................. w..... '� .. _.... . _ . . _ __ . .___„_ ........._
•
'1 .of Burial r x l}: _..- -_._..._... �....w.......- -.....
_...�', of body is to bet y held, Ili ace lat ---" .—
Cemetery_—.. _ .. ,-»_- ...._._ _ _ Date of B fiat _, J.._ 19101`�
(If body is to be temporarily held,fill in space later) -.. .
The Certificate of Death containing the above stated particulars, having been presen 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, ve recorded it in my Local Record with above stated Registered Number,
and on e I HE BY ,Fl PERMIT .._ ..M _ . ...._. ........_ » .... .-.. ....._...�!..
( ame) (Address)
the.. to hold temporarily and_ e y.
( rtaker or person i g charge of corps. (Inter, reprove, or o 'se �i.�p se of [state w .
Dated.. - / ir 19.1, s (Signed) ........._..._.. __._ ,Gt.7�G L
Local Registrar
Permit is sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to local story
or other regulations), unless removal is by common carrier,in which case a Transit Permit (VS No.62) is required.
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