Hayes, Edwin Form VS 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
'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. .S Co 0 ( Registered No. 3 .2-..
/ , Town 0 ��County w Village
or City (If city,give street address)
Name of eceased ( "C,f...L Vs‘
Single,married,widowed, •
Sex .Color...(lLJ • or divorced (write the word) ate o eatl - 2. 19 •. a`7—
Age 6 Y rs 43 Months S Days Birt lace Cause of Death 1: /.j. .. e� „.' ,l/". ...
Certificate was signed by ��� l ' , M.D.--)r,„
Address tit)_to_al. ... .
-
Place of Burial Removal)
(If body is to be tem a ily held,filhin spac I er)
Cemetery • etetit_Q, Date of Burial.... Q. 6 19...r sJ
(If body is to be temporarily held,fill in space later)
The Certificate of Death containing the above stated particulars, having been presente 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 oi basis there f I 1EB Y RANT A PERMIT , C��� /
��
'the to hold temporari's --II .the body.
(Und t -er or person avigg charge of rps or arise 'n o tate how]).
Dated GC.-fd..l ,. 19 (Signed
Local Registrar
This it is sufficient for the Removal (and interment or C ti o o any part of the State (su jeci to local cemetery
or other regulations), unless removal is by common carrier, in which case a ransit Per (VS No. 62) is required.
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