La Barge, Augustus rorm VS 01. 11.23-33. %000 (17.3194)
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
1r 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� Z WRITTEN IN DURABLE BLACK INK.
Dist. No...... .._ '�C / Register No....
"-� Town, �//fJ,
County i ».».. »Village . ,,/
1 /� II br (If city, give street address)
Name of deceased .� . (. _ .._. ._.„»
Single,married,widowed, s� - SS
Sex M olor ..........P or divorced (writ word). __ . ate �f ,ath 19.�......
Age .. ...Years.. .... ... ..1) Mo s... , D,,V Birth lac9 ( „
Cause of Death .
Certificate was signed by ,
Address......»...„...„.......».». ». . I r
i Place of Burial r Rehm or ».. „.... ... ... ...
(If body is to be tern r d, p la ) » „
Cemetery .( ...' "r- leat..f... Date of Burial F 19
(If body is to lie temporarily held, fill i pace later)
The Certificate of Death co ining the above stated particulars, having been presented to e, 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 Reco with the above stated lj gistered Number,
and o t e basis thereof I HER RAT A PERMIT
)1A-ri...--a-lr_. -- .. < - , , r ri-er_.-(26 1'1 r W
(Name) (Address)
the �� to hold temporarily nd y „.».....„„.»..»„„.„.....„..»„. body.
( eye• or erso a 'rg charge of p ) (Inter, remove, o°/ot.l 'se disp of [state
Dated �! 19...� (Signed):.. ».r.„
„Local Registrar
This Permi s sufficient for the Removal (and Interment or Cremation) of a body to any part of the State (subject to lolal 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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