Hart, Alexander Form VS 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'M- 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. 5-6 0 I Registered No. .2 .r.
TV
County W ec-/-4/7- Le. -Village
City (If ' ,give street dress)
ty...7419fec... 2_y
Name of eceased
r"d‘eingle,married,widowed,
Sex Color . or divorced (write the word)..<1.) ..e.4..... .... ... . . ate ath ' • ?0..19
Age 70 Ye -s ci .1 -'onths / V' Days Birthplace. - P
Cause of Death ' -eik/i4
, . A
a --V
Certificate was s' ed by ir1V/6.rN:CCLIji,
Address ---, ... . ti:.
Place of Buria (o Re oval) '
(If body is to be te
j,,u...47
Cemetery Da of Burial - ,==. ? 19..3.-S—
(If body is to temporarily held,fill in pace later)
The Certificate of Death containing the above stated particulars, having been presented to m , 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 l'e ba heilI HEREBY GRANT A PERMIT
,...
to. .0, P0- ./e) , ,
as) '
-- ,-e./2) to hold temporarily -id tli body.
(u rt ker or person haviy charge otic3pie) ' ,remove,or of),.ttpvise di i late ho 7).
Dated ,.. • -.V--,, .19.:./ (Signed)"
Local Registrar
This Permit is ufficient for the Removal (and Interment or Cremation a o y to ty part of the State (subject to local cemetery
-,r other regulations), unless removal is by common carrier, in which case a ansit Permi (VS No. 62) is required.
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