Mickel, George Form VS 61. 1-23.35.25,000 (17.5154)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
sir 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 W1tIT1'EN IN DURABLE BLACK INK.
Dist.No. �// Registered No. / Li .._
---County d �/ TownVillage._..»..
or C ty (If city,give street address)
Name of deceased . - 9 .%l--
Single,married,widowed,
Sex.... ...»»....Co cr or divorced (write the wor ..»..Date of eath 19 S---
Age..._..»..... .4Years sue.. Months
.. .. .Days , Birthplac
Cause of Death..._. ». . �� � ».1� .......» .» ...._...
Certificate was signed by -- »» M.D.
Address. _.............r..
Place of Burial (or Removal). ».». ,.....
(If body is to be temporarily held,fill in space later)
Cemetery _ _ /-_ :, . .....Date of Burial .2 7 ...19....�...1
(If body is to be temporarily held,fill in space Eater)
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 the basis thereofVI REBY GRANT A P IT
to / � � ....»..»... ...»»
am G�R� {� (Address)
the ... ... ... ... . ... . .. ..... to hold temporarily an . .. .. the body.
(Under ke r person hying charge of corpse) _ t�3 ove,or therwise dispose of[state how]).
Dated.......».». .. - 19--- 3 (Signed)
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.
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