La Rich, Arnold Form VS 61. 6-8-34-50,000 (17-7901)
NEW YORK STATE DEPARTMENT MENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
F 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. 9.5 6 q 7 Registered No.
Town
County - loge . •••
4,--C4t 7 city,give street address),
Name of deceased ........1 .,- i
/,, Single,married,wi wed,
Sex127 LLColorI'1 .or divorced (write e word) Q5-ei..:44-,62 Date of Death a2 k 19..~,ts...0.
Age Year Months l Birthplace....
Cause of Death 2 ^r..41 . .. �/
Certificate was signed by , M.D.
Address / �/
Place of Burial (or Removal) f r��f..�� �4 � Y2-
(If body is to be temporarily d, 11 ins e ter) �y
Cemetery it. • e :.Keg.J Date of B rial (" .. ... - 027 1900
(If body is to be temporarily held,fill in space:ater)
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 cord with the above stated Registered Number,
and on the basis thereof ERR1' GRANT A PERMIT ,
to.... tI ... ......' 1 4:
T4
the....e i / �L s.sl r f�l Lt..L....&Ui.:-to hold temporarily -xi the body.
ertaker or person having charge o,co�se) ,rem ,or otherwise dispose of[state how))
Dated - a t--�./ .r..`'19..., (Signed) / :` ;.,..., `. "_=`a r'rs.-r
Local Registrar
This Permit is sufficient for the Removal (and Interment or CremationYo 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.
P.
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